DOE Credentialing and Reimbursement

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DOE Credentialing and Reimbursement

• Maureen Dermody Bouris M.Ed. RN CDE CDOE
• February 13, 2008

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BY-LAWS

• Article III. General Membership
• Section 2. Educational Requirements
• Attend a minimum of two (2) general DOE meetings
  ( there are four offered) and obtain six (6)
  hours of continuing education related to diabetes
• Article III. Board Membership
• Section 1. Composition
• Fifteen to twenty-five members representing all
  disciplines RN, RD, RPh

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BY-LAWS (contd)

• Article VII. Responsibilities
• Section 4. Function of Board committees
• Bylaws and Policies, Certification Program,
  Certification Exam, Continuing Education,
  Credentials, Curriculum, Nominating and
  Reimbursement. See sections 4A-4G for a
  description of committee functions
• Please note All DOE educators are encouraged to
  join at least one committee. If you have
  suggestions, concerns, or issues join the
  appropriate committee!

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RIDOH DOE Program Policies

• I. Requirements for Certification as a DOE
  Educator
• A. Three years experience as an RN, RD, RPh
• B. Licensed as an RN, RD, RPh
• C. Must have 12 hours of volunteer diabetes
  experience
• D. Complete the DOE certification process
• 1. Mandatory attendance at basic, advanced,
  practicum, and process education sessions
• 2. Required readings

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Program Policies (contd)

• 3. Passing the teaching component in one of four
  (4) ways
• 1) Attend a group class and teach a topic in
  your specialty
• 2) Observe a TEAMworks program and teach a
  component
• 3) Observe and perform a one-on-one counseling
  session
• 4) Participate in a live case study
  presentation
• see notes on this

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Program Policies (contd)

• 4. Passing the CDOE exam
• See sections a through d for instructions if exam
  is not passed on the first try
• e. Must submit the CDOE Certification Form to the
  RIDOH DCP within nine (9) months of passing the
  exam

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Program Policies (contd)

• II. Special Situations - A. Current CDEs
• III Third Party Insurer Reimbursement
• -A. CDOE submits completed Certification
  Completion Form to the RIDPCP
• -B. RIDPCP contacts insurers to inform them the
  CDOE is certified
• -C. RIDPCP issues the CDOE Certification
• -D. CDOE contacts insurers for provider
  applications
• -E. CDOE informs the RIDPCP when he/she is
  issued a provider number

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Program Policies (contd)

• IV. Yearly Requirements to Maintain CDOE
  Certification
• A. Attendance at a minimum of two (2) quarterly
  general DOE meetings
• B. Teach a minimum of one (1) DOE group class or
  twenty (20) individual sessions per year
• C. 1. Obtain a minimum of six (6) Contact Hours
  per year in diabetes and/or related education

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Program Policies (contd)

• C. Continuing Education
• 2. A maximum of three (3) contact hours may be
  applied towards the continuing education
  requirement if the CDOE teaches
• A completed CDOE Annual Certification
  Requirements Form must be submitted by January
  31st of the following calendar year to maintain
  certification
• 45. In lieu of teaching requirements, a CDOE
  may obtain twenty (20) hours of yearly continuing
  education for a period not to exceed three (3)
  years

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Program Policies (contd)

• D. Aggregate Data Forms must be submitted for one
  quarter, a three (3) month period as determined
  by the RIDPCP. (Usually April, May and June each
  year)
• Aggregate Data Forms are necessary for the
  RIDPCP to keep statistics on our program and
  services, to assist with funding, and plan to
  improve gaps in service.
• Aggregate data forms are very important if you
  wish to become nationally certified as a CDE.
  You must prove you have 1000 hours of diabetes
  education in a five (5) year period before you
  can sit for the exam. (The application for CDE
  was harder to do than the exam!)

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Program Policies (contd)

• E. Annual Certification Requirements Forms
  received after January 31st will be subject to a
  25.00 late fee up until February 15th
• F. Forms not received by February 15th will
  result in a one-year (1) probationary period
  with additional requirements

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Program Policies (contd)

• CDOEs who do not fulfill these additional
  requirements or do not request inactive status
  (See Section V) will be removed from the active
  CDOE list effective March 1st resulting in
  ineligibility for third-party reimbursement and
  additional requirements for reinstatement
• Fill out the Annual Cert. form on time!

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Program Policies (contd)

• V. Inactive Status
• A. CDOE may choose the option of inactive status
  for a period of no less than six (6) months and
  up to one (1) year
• 1. Must submit request in writing
• Must request return in writing
• Must fulfill all DOE program requirements
• The RIDPCP is not responsible for any of this
• If 2 is not done penalties apply!

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Program Policies (contd)

• VII. DOE Site
• A. Classifications Institution, Physicians
  office, Independent private practice
• Note a personal name for an organization name
  is not allowed
• If you are considering starting a new CDOE Site,
  refer to the requirements Section VII, B, 1-10,
  of the Program Policies.
• Suggestion Partner with another DOE site for
  assistance.

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Reimbursement

• As of May 23, 2007 all providers must have a
  National Provider Identifier (NPI)
• By May 23, 2008 all providers must use this
  number exclusively on all claims-disregarding old
  provider numbers. BCBSRI is requiring this May,
  1, 2008. WHY? Who Knows?
• All CDOEs must apply for an NPI Type 1 by
  completing the application online at
• https//nppes.cms.hhs.gov

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Reimbursement (contd)

• What does the NPI do?
• Replaces all other provider numbers
• Establishes a national identifier for providers
  (can easily track providers)
• Simplifies (?!?) health care system
  administration by encouraging electronic claims

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Reimbursement (contd)

• What does the NPI not do?
• Replace the tax identification number, this is an
  IRS requirement
• Guarantee reimbursement by health plans
• Enroll providers in health plans, you must still
  go through each insurers credentialing process,
  but obtain your NPI first

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Reimbursement (contd)

• Blue Cross Blue Shield and United Health Care
  Credentialing process
• Call 888-599-1771 to obtain a CAQH pin number
• Log onto the CAQH website at
• www.caqh.org/credapp
• to complete the application

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Reimbursement (cont)

• Neighborhood Health Plan of Rhode Island
• Not yet on CAQH website
• Contact the Network Development Credentialing
  department at 459-6000 or 1-800-963-1001 and
  request a Provider Credentialing Application
• You will need all the same info. as for CAQH

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Reimbursement (contd)

• Council on Affordable Quality Healthcare
• CAQH is a universal credentialing data source
• It is the on-line credentialing process for RI
• Its initiative is to standardize the
  credentialing application process so that
  providers do not have to fill out multiple
  applications with essentially the same
  information

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Reimbursement (contd)

• Call 888-599-1771 for CAQH PIN number
• Log onto www.caqh.org/credapp
• Do the tutorial first and write down all of the
  information/paperwork/dates you will need for the
  application
• Allow two (2) hours to do the application
• It is a smart program skipping pages that do
  not pertain to you

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Reimbursement (contd)

• Read the FAQs and Commonly made mistakes and
  dont make them!
• Maureens helpful hints
• Simplify! Do the on-line not paper application
• Have all the necessary paperwork next to you
• Do application on a separate day from tutorial
• Put one place of employment-8 pages each!
• Have no covering professionals-4 pages each!

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Reimbursement (contd)

• You will have to re-attest every 120 days
• If your organization bills for you, you do not
  have to participate in CAQH, but you will be much
  more marketable should you ever leave your
  present employment and you need your own provider
  numbers if you would like to see patients
  privately

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Reimbursement (contd)

• Medicare and HMO for Medicare products (BlueCHip
  for Medicare and United Medicare Complete)
• Can only be reimbursed through an American
  Diabetes Association (ADA) recognized site.
  Currently there are twelve (12) ADA sites in
  Rhode Island.
• Consult the DOE Site listing for specific sites

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Reimbursement (contd)

• RDs may bill Medicare and Medicare products
  without ADA Site affiliation.
• RDs can bill Medicare for individual sessions if
  they receive an order for medical nutrition
  therapy
• Call Medicare Part B Provider enrollment at
  1-866-582-3251 to obtain a provider application
• Medicaid Cannot be billed

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Reimbursement (contd)

• Hospital/Physician office/Institution billing
• Talk to the billing coordinator to discuss DSME
  education and how to bill
• Billing coordinator can partner with a like
  agency for questions
• Community/Individual billing
• Use the Health Insurance Claim Form CMS-1500
• (08-05), available at Staples or Office Max
• Fill out the CMS-1500 form for each participant,
  can include six (6) sessions on one form

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Reimbursement (contd)

• Reimbursement depends on obtaining a referral for
  HMO clients (BlueChip and United) and orders from
  the physician for Medicare and non-HMO BC/BS
  plans
• Suggestion Partner with a CDOE in a like agency
  to review procedures before billing
• Contact the appropriate provider relations
  representative with questions

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Reimbursement (cont)

• Our provider relations representative at BCBSRI
  is Phyllis Bailey at 459-5411, fax
• 459-5531 or phyllis.bailey_at_bcbsri.org
• If you have difficulties with third party
  insurers regarding payment there is a resource at
  the DOH
• Bartlett Rollin at 222-2223 or
• rollin_bartlett_at_dbr.state.ri.us

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RI CDOE Web Site

• Please visit the RICDOE Web Site for information
  on news and events, meeting minutes, job
  postings, clinical information, and other CDOE
  staff at
• www.ridiabeteseducators.org
• It is our vehicle of communication!

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The End

• Thank you!