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1 The 2 nd Annual Client Conference October 16 th & 17 th, 2006 Welcome to the Network “Credentialing” Leona Roach, CPMSM, CPCS.

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Presentation on theme: "1 The 2 nd Annual Client Conference October 16 th & 17 th, 2006 Welcome to the Network “Credentialing” Leona Roach, CPMSM, CPCS."— Presentation transcript:

1 1 The 2 nd Annual Client Conference October 16 th & 17 th, 2006 Welcome to the Network “Credentialing” Leona Roach, CPMSM, CPCS

2 2 Discussion Glossary Glossary The New Provider ~ New to CCNV Network The New Provider ~ New to CCNV Network Established Provider ~ Already In CCNV Network Established Provider ~ Already In CCNV Network

3 3 Glossary Completed application ~ Questions answered; yes answers explained; application is signed; required documents listed on application are attached; letter of coverage; references are provided with contact information; Completed application ~ Questions answered; yes answers explained; application is signed; required documents listed on application are attached; letter of coverage; references are provided with contact information; Network contracted 3 rd party agreements ~ Contracts negotiated at CCNV for our Health Centers Network contracted 3 rd party agreements ~ Contracts negotiated at CCNV for our Health Centers Non-contracted 3 rd party payer agreements ~ Contracts negotiated by the Health Center for the Health Center Non-contracted 3 rd party payer agreements ~ Contracts negotiated by the Health Center for the Health Center Delegated credentialing contracts ~ Network contracted 3 rd party payers who accept the CCNV Board decision for their credentialing process Delegated credentialing contracts ~ Network contracted 3 rd party payers who accept the CCNV Board decision for their credentialing process PSV ~ Primary source verification PSV ~ Primary source verification

4 4 Credentialing Staff Cynthia Roberts, Senior Credentials Analyst Cynthia Roberts, Senior Credentials Analyst Key Health Center Credentialing Contact Key Health Center Credentialing Contact Tamika Rodriguez, Credentials Analyst Tamika Rodriguez, Credentials Analyst Angee Smith, CPCS, Credentials Analyst Angee Smith, CPCS, Credentials Analyst Leona Roach, CPMSM, CPCS, Director Leona Roach, CPMSM, CPCS, Director

5 5 The New Provider When does the credentialing process begin? When does the credentialing process begin? During employment negotiations During employment negotiations Health Center pre-employment requirements Health Center pre-employment requirements Provide the CCNV application for completion Provide the CCNV application for completion I have a signed employment contract, now what? I have a signed employment contract, now what? Forward the application and required documents to CCNV Credentialing in timely manner Forward the application and required documents to CCNV Credentialing in timely manner

6 6 The Clock Begins ~ Working Days 1-2 When CCNV receives a completed application When CCNV receives a completed application Delays occur in processing if application is not complete Delays occur in processing if application is not complete Data entry and PSV is started within 24 hours of receipt of completed application Data entry and PSV is started within 24 hours of receipt of completed application CAQH, Medicare and NPI applications are updated or generated by Credentials Analyst CAQH, Medicare and NPI applications are updated or generated by Credentials Analyst

7 7 Working Days 3-5 CCNV Network contracted 3 rd party payer applications are filled out CCNV Network contracted 3 rd party payer applications are filled out Non-contracted 3 rd party payer applications are filled out Non-contracted 3 rd party payer applications are filled out Must be provided by Center ~ not an assumption that can be made Must be provided by Center ~ not an assumption that can be made 3 rd party applications are then mailed to the Health Center’s Credentialing Contact 3 rd party applications are then mailed to the Health Center’s Credentialing Contact

8 8 Working Days Center receives applications from CCNV Center receives applications from CCNV Each application must be reviewed for accuracy and completeness by provider Each application must be reviewed for accuracy and completeness by provider Provider must answer questions and sign all documents as required Provider must answer questions and sign all documents as required Executive Directors may also be required to sign documents (Medicare) Executive Directors may also be required to sign documents (Medicare)

9 9 28 Calendar Days Center ? ~ My provider has been here 4 weeks, we haven’t received any provider number’s or effective dates? Center ? ~ My provider has been here 4 weeks, we haven’t received any provider number’s or effective dates? CCNV ? ~ Have you received the 3 rd party applications from CCNV? CCNV ? ~ Have you received the 3 rd party applications from CCNV? CCNV ? ~ Have the applications been verified, signed and sent back to CCNV? CCNV ? ~ Have the applications been verified, signed and sent back to CCNV?

10 10 Working Days rd party payer applications are received by CCNV from Health Center 3 rd party payer applications are received by CCNV from Health Center Are they complete? What’s left to do? Are they complete? What’s left to do? Each application must be prepared for mailing Each application must be prepared for mailing Copies of Licenses, DEA, FTCA/Malpractice, Board Certifications, completed applications and other documents required by insurers. Copies of Licenses, DEA, FTCA/Malpractice, Board Certifications, completed applications and other documents required by insurers. Applications are mailed to Network contracted and non-contracted 3 rd party payers Applications are mailed to Network contracted and non-contracted 3 rd party payers

11 11 Working Days PSV is completed and provider is accepted into the Network by the CCNV Board of Directors PSV is completed and provider is accepted into the Network by the CCNV Board of Directors CCNV delegated 3 rd party payers are sent provider demographics and verification of the CCNV credentialing process CCNV delegated 3 rd party payers are sent provider demographics and verification of the CCNV credentialing process Center: CCNV notified us that our provider was accepted by the CCNV Board ~ When can we expect to begin receiving provider #’s and effective dates? Center: CCNV notified us that our provider was accepted by the CCNV Board ~ When can we expect to begin receiving provider #’s and effective dates? Delegated payers ~ Approval date to 45 days Delegated payers ~ Approval date to 45 days Contracted ~ Can be up to 90 days Contracted ~ Can be up to 90 days Out of Network ~ Can be up to 180 days or more Out of Network ~ Can be up to 180 days or more

12 12

13 13 Working Days CCNV contacts all Network contracted and non- contracted 3 rd party payers to verify receipt of the providers application for their credentialing process CCNV contacts all Network contracted and non- contracted 3 rd party payers to verify receipt of the providers application for their credentialing process Not in system ~ follow-up 5 days Not in system ~ follow-up 5 days Yes ~ date is documented and follow-up schedule begins Yes ~ date is documented and follow-up schedule begins

14 14 The Tracking Schedule Two weeks from verification of receipt Two weeks from verification of receipt Do you need anything/have any questions? Do you need anything/have any questions? Four weeks from verification of receipt Four weeks from verification of receipt Where are you in the credentialing process? Where are you in the credentialing process? Ready for your credentials meeting? When does your committee meet? Ready for your credentials meeting? When does your committee meet?

15 15 Meanwhile at CCNV Tracking continues until provider numbers and effective dates are received or up to 90 days Tracking continues until provider numbers and effective dates are received or up to 90 days Upon notification of provider numbers, effective dates, approval notices ~ CCNV provides information to the Center’s Credentialing Contact Upon notification of provider numbers, effective dates, approval notices ~ CCNV provides information to the Center’s Credentialing Contact

16 16 Meanwhile at Health Center Health Center is completing the credentialing and privileging approval process with their Board. Health Center is completing the credentialing and privileging approval process with their Board. Upon receipt of provider numbers and effective dates from CCNV ~ Health Center is notifying ComCare for data load into Megawest Upon receipt of provider numbers and effective dates from CCNV ~ Health Center is notifying ComCare for data load into Megawest If Health Center is receiving provider information from 3 rd party payers, this is being disseminated to CCNV Credentialing and ComCare immediately If Health Center is receiving provider information from 3 rd party payers, this is being disseminated to CCNV Credentialing and ComCare immediately

17 17 In the Case of Missing Numbers After 90 days of tracking and not obtaining the necessary elements from the Network contracted 3 rd party payers ~ CCNV Contracting is notified and begins investigating. After 90 days of tracking and not obtaining the necessary elements from the Network contracted 3 rd party payers ~ CCNV Contracting is notified and begins investigating. Center is notified that no response has been received from non-contracted 3 rd party payers Center is notified that no response has been received from non-contracted 3 rd party payers After 90 days from the CCNV Board approval date, the CCNV Credentialing process is now considered completed. After 90 days from the CCNV Board approval date, the CCNV Credentialing process is now considered completed.

18 18 The Established Provider Moving Within Network An employment contract has already been negotiated. An employment contract has already been negotiated. Does my provider need to fill out another CCNV application? Does my provider need to fill out another CCNV application? Does my provider have to go through the processing of all those 3 rd party payer applications again?! Does my provider have to go through the processing of all those 3 rd party payer applications again?!

19 19 Does My Provider Have to …. Fill out a CCNV application? Fill out a CCNV application? Yes and No ~ Center can request CCNV to send a pre-populated application (basic demographic, education, training information) Yes and No ~ Center can request CCNV to send a pre-populated application (basic demographic, education, training information) Must be updated ~ (office information, questions answered, current references, new attestation) Must be updated ~ (office information, questions answered, current references, new attestation) Why, the provider is already in the CCNV Network? Why, the provider is already in the CCNV Network? Each Health Center must have a PSV file on each provider. Each Health Center must have a PSV file on each provider. Provider does not go through the CCNV Credentialing/Board Provider does not go through the CCNV Credentialing/Board MUST go through Health Center’s Board approval process. MUST go through Health Center’s Board approval process.

20 20 Does My Provider Have to …. Go through all the 3 rd party payer process again? Go through all the 3 rd party payer process again? Not necessarily, but there are reasons that may necessitate redundancy Not necessarily, but there are reasons that may necessitate redundancy Provider was termed from CCNV Network longer than 30 days prior to new employment Provider was termed from CCNV Network longer than 30 days prior to new employment Your Center may have other CCNV Network agreements not available at previous Center Your Center may have other CCNV Network agreements not available at previous Center Your Center may have non CCNV agreements contracts that previous Center did not have Your Center may have non CCNV agreements contracts that previous Center did not have

21 21 Must Take Place CAQH update CAQH update Medicare update Medicare update NPI update NPI update Health Center Credentialing and Privileging approval process Health Center Credentialing and Privileging approval process

22 22 To Add it Up The Process Takes Time and Two Way The Process Takes Time and Two WayCOMMUNITCATION

23 23 DISCUSSION/QUESTIONS THANK YOU


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