1. Physician Credentialing & Enrollment

2. Objective At the end of this presentation, you should be able to
Follow Harvard Pilgrim Health Care’s procedures for initial credentialing of clinicians
Understand Harvard Pilgrim Health Care’s procedures for re-attestation/recredentialing of clinicians
Recognize when and how to submit provider enrollment changes to Harvard Pilgrim

3. Agenda Initial Credentialing Re-Attestation & Recredentialing
Provider Enrollment Changes

4. Initial Credentialing

6. Clinicians Credentialed by Harvard Pilgrim
Physical therapists, occupational therapists, and speech/language pathologists
Master’s level clinical social workers
Master’s level clinical nurse specialists, psychiatric nurse practitioners
Other behavioral health care specialists who are licensed, certified, or registered by the state to practice independently
Audiologists
Nutritionists/registered dieticians
Hearing instrument specialists–New Hampshire and Massachusetts only
Physician assistants (P.A.)–Massachusetts only
Naturopaths–NH and CT only
Medical doctors (M.D.)
Doctors of osteopathy (D.O.)
Doctoral level and master’s level psychologists
Chiropractors (D.C.)
Dentists (D.D.S./D.M.D.)
Optometrists (O.D.)
Podiatrists (D.P.M.)
Certified midwives (CM)–New Hampshire only
Certified nurse midwives (C.N.M.)–Maine and New Hampshire only
Nurse practitioners (N.P.)–Massachusetts, Maine and New Hampshire only

7. Clinician Credentialing Prerequisites
Current, unrestricted license for each practice discipline
Board certification, or board training in specialty
Hospital admitting privileges, or alternate coverage arrangements at a Harvard Pilgrim-contracted facility
Minimum malpractice coverage required
A contract with Harvard Pilgrim, or with an entity that is Harvard Pilgrim contracted

8. Health Care Administrative Solutions (HCAS)
A non-profit entity founded by several Massachusetts health plans to collaborate on administrative simplification initiatives
Centralizes and streamlines components of the credentialing process that are common to all participating health plans

10. Initial Credentialing Process Overview
Who
Action Required
Provider
Complete HCAS Provider Enrollment Form & send to HPHC
HPHC
Review & send information to CAQH
CAQH
Send instruction packet to provider
Complete online CAQH credentialing application
OptumInsight
Verify provider data and send to HPHC
Credentialing Committee review
Send out Welcome letter to providers approved by committee

11. HCAS Provider Enrollment Form

14. Completed HCAS Provider Enrollment Form
Harvard Pilgrim Health Care
Attn: Provider Processing Center
1600 Crown Colony Drive 2nd Floor
Quincy, MA 02169  
Questions? 
Provider Service Center,

15. A central repository for credentialing information
A central repository for credentialing information

16. CAQH Credentialing Application
CAQH User
Submission options
Existing
Update information Or
Call CAQH Help Desk for assistance:
New
Fax:

17. Harvard Pilgrim Approval Process
Report of new providers received from OptumInsight by Harvard Pilgrim Credentialing department
Review of providers’ clean & complete applications by Harvard Pilgrim Credentialing Committee at weekly meeting, except Rhode Island providers. (Due to RI state law, they need to be reviewed at the monthly Clinician Credentialing Meeting)
Welcome letter sent to providers approved by Credentialing Committee

18. Key Contacts For assistance with Contact
HPHC Credentialing requirements & processes
Harvard Pilgrim Health Care: 
HCAS Enrollment Form
Locating, completing, submitting, etc.
  
HCAS:
CAQH Credentialing Application
Completing/updating, submitting, checking status, etc.
CAQH:
 Help Desk:
 (New only) 

19. Re-Attestation/Recredentialing

20. Re-Attestation
reminder to providers to review and attest to the accuracy of their data every 120 days
Online at or
Contact CAQH Help Desk at
Facilitates compliance with requirements of each participating plan with which provider is contracted
Keeping data current allows participating plans to access current information at the time of recredentialing, without having to contact the provider for the information
Harvard Pilgrim affiliated clinicians are reviewed every two or three years, depending on state law. As of February 2007, all clinicians are required to complete their credentialing/recredentialing through the HCAS process.

21. Recredentialing If re-attestation Then Has been completed
Provider will need to do very little
Has not been completed
Provider will need to update information, which will require more time
Has not been completed and information has not been updated
Provider may need to go through initial credentialing process again

22. Provider Enrollment Changes

23. Overview
Updates to your provider practice information is your responsibility as an HPHC participating provider
Prospective written notification is required for all changes with Harvard Pilgrim and must be submitted using the Provider Change Form
A minimum of 60 days written notice is required for LCU changes
A minimum of 30 days notice is required for non-LCU level changes
Practice changes made in CAQH’s Universal Provider Datasource – address, phone numbers, new associates, etc – also need to be communicated to plans directly

24. Importance of Changes Notification
Each of the following can impact members, payments and/or provider satisfaction:
PCP panel status
New practice location
New practice name or tax ID #
Change of contract
Change of payment address

25. Provider Change Form

27. Questions?