Provider Credentialing Unraveled: A Comprehensive Manual

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Credentialing 101
A Detailed Guide to Provider Credentialing
A Webinar Presented by Cati Harris, CBCS,
CPCS Director of Provider Credentialing - Solor,
Inc
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Cati Harris, CBCS, CPCS
Director of Provider Credentialing Contracting
Solor, Inc.

• Professional Experience
• Over 20 years experience in Medical Billing,
  Coding, Provider Credentialing/Contracting
• 15 years of clinical experience
• Currently provide credentialing services for 2
  major hospital systems, and 11 private practices
  (35 physicians/PA/NP)
• Educational Experience
• Diploma with Honors in Medical Billing Coding
• Certi?ed Billing and Coding Specialist
• Certi?ed Provider Credentialing Specialist

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Learning Objectives

• Welcome to the Webinar! Credentialing 101 A
  Detailed Guide to Provider Credentialing. This
  webinar focuses on the preparation, submission,
  and completion of the provider credentialing
  process helping to improve the tracking,
  accuracy, timeliness, and compliance of your
  provider enrollment process.
• When to start credentialing
• Setup and Maintenance of NPPES, IA Management
  System, CAQH, PECOS
• How to review, validate, and track provider
  documents
• How to Prepare, Review, Submit, and Track Payer
  applications
• Items to complete once the provider is
  credentialed/contracted
• Linking of a previously credentialed provider
  with payers to your tax id/contracts
• Brief overview of Provider Revalidations

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Credentialing Keys to Success

• Research
• Preparation
• Tracking
• Communication

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RESEARCH

• Research is the key to SUCCESSFUL Provider
  Credentialing
• The research process is divided into two parts
• Provider Research
• Payer Research

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Provider Research

• Provider Research includes questions to ensure
  you have the vital information to proceed with
  the Providers credentialing.
• Does the provider have a registered NPI?
• Is the provider newly licensed?
• What is the providers anticipated start date?
• State Approved Medical License
• Does the provider have any disciplinary actions,
  previous criminal charges, or malpractice
  claims?
• Mid-Level - Is the supervising md approved?
• Mid-Level - Is the collaborative agreement
  signed?
• Has the provider been previously credentialed
  with payers?

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Research - Payer

• Payer Application and Document Requirements
• Copy of Application and Applicable Forms
• Online Payer Application Location
• Payer Estimated Processing Time
• Payer Preferred Submission Method
• Payer Contact Information
• Website, Email, Phone, Fax
• Payer Provider Representative Contact Information

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NPPES, CAQH, Identity Access Management, PECOS

• When credentialing a provider, you will need to
  access various management systems to ensure the
  information is accurate, current, and attested.
  The managements systems to access
• NPPES
• Identity Access Management System
• CAQH
• PECOS

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NPPES

• NPPES - https//nppes.cms.hhs.gov//
• Obtain Login/PW or Setup access (The login for
  the IA System is the same for NPPES)
• Verify Provider Information
• Correspondence Address and Practice Address
• Provider Contact Information
• Phone number, Email
• Taxonomy
• Delegated Access
• Provider IDs
• NPPES Must be current and approved before
  proceeding with any provider credentialing.
• Print out any update con?rmations completed

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Identity Access Management System

• I A Management System - https//nppes.cms.hhs.go
  v/IAWeb/login.do
• Obtain Login/PW or Setup access
• Verify Provider Information
• Correspondence Address
• Practice Address
• Phone number, Email
• Delegated Access

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CAQH

• CAQH - https//proview.caqh.org/Login/Index?Return
  Url2f
• Obtain Login/PW or Setup access
• Review/Complete each section
• Add your information in the credentialing contact
• Add your email on the provider info page as a
  secondary contact
• Ensure the Authorization Section is Checked to
  Allow all Payer Access
• Upload the following documents
• Attestation
• Certi?cate of Insurance
• State License
• DEA
• Provider CV
• Board Certi?cation
• Med School Degree including any Residency or
  Fellowship Cert

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PECOS

• PECOS - https//pecos.cms.hhs.gov/pecos/login.doh
  eadingLv1
• The login for PECOS is the same username and
  password used for IA Management System
• Select My Associates
• Scroll to bottom and check for current
  enrollments
• If provider is currently enrolled, check to see
  if the provider is enrolled with the correct
  state and MAC.
• If provider is not enrolled, you will select to
  start the process.
• Complete all tabs, run an error check, locate
  name of group authorized signatory for the
  reassignment of bene?ts
• Once error check shows no errors, you can
  complete submission
• Be sure to print out copy of application and
  submission
• You will receive email con?rmation
• Re-Validations
• Select revalidation noti?cation center instead of
  My Associates

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Tracking is the single action that can ensure
timely, e?cient submission and processing of the
providers payer application package.
Tracking

• Lack of tracking can lead to
• Payer misplacing application package
• Delayed application submission and processing
• Missed request for more information, missing
  documentation
• Application being Red Flagged by Payer
• Financial loss and increased credentialing costs

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Once the Provider Credentialing is Approved..

• What is next?
• Request copy of approval/welcome letter from
  payer
• Request payer speci?c provider
• Inquire when the revalidation will be due
• Request copy of contract and fee schedule
• Review both the contract and fee schedule prior
  to signing
• Once signed, request copy of signed contract
• Create Master Information Sheet with payer
  speci?c information
• Credentialing effective date
• Payer Speci?c Provider
• Contract Effective Date
• Fee Schedule Effective Date

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Are you in need of an experienced credentialing
professional?
If you answered YES, please contact me to
arrange your free consultation for
credentialing services.
Cati Harris, CBCS, Director of Provider
Credentialing Solor, Inc Phone
704-675-7279 Email cballard_at_mysolor.com
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Questions?
Cati Harris, CBCS, Director of Provider
Credentialing Solor, Inc Phone
704-675-7279 Email cballard_at_mysolor.com Thank
you for your time and attendance!
Register Now