Provider Credentialing Overview

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Linking

Connects providers to a shared Tax ID for contracting purposes

Medical Education Diploma

Copy of diploma or transcript for state and hospital credentialing

CAQH Number

Credentialing database access for healthcare providers

Commercial Insurance Payer Credentialing

Credentialing process for commercial insurance providers, distinct from Medicare

Medicaid Credentialing

Credentialing requirements and process for Medicaid participation

Current Liability Ins

Current liability insurance details, including coverage amounts

CV

Curriculum Vitae detailing provider's education and work history

Malpractice Claims

Disclosing history of malpractice claims for credentialing transparency

Contract vs. Credentialing

Distinguishes between contractual agreements and the vetting process for providers

Credentialing Calendar

Document listing payer names, contact info, submission method, dates, and contract effective dates for tracking enrollment status

Necessary Documentation

Documents required for credentialing process, includes personal and professional details

Credentialing Timeline

Duration dependent on provider compliance and documentation submission

HIPAA

Health Insurance Portability and Accountability Act for patient data protection

Provider Relations Representative

Individual assisting with provider status inquiries and credentialing process

Red Flags

Issues causing payer delays: frequent job changes, unexplained work gaps, negative references, fraud claims, malpractice suits, incorrect/misssing info, unexplained criminal activity, incorrect ink color, outdated signature

Delays to the Process - 'Red Flags'

Issues that hinder credentialing progress, signaling potential problems

Credentialing Other Nonphysician Providers

Process for vetting and credentialing non-physician healthcare providers

Contracting

Process of establishing agreements with payers.

Payer Credentialing

Process of provider joining insurance networks, includes completing requirements, submitting documents, and signing contracts for reimbursement

Medicare Credentialing

Process specific to Medicare participation, includes NPI acquisition and application types

Board Certification

Proof of board certification, including initial and recertification dates

Loading

Provider activation after linking to a Tax ID.

Individual NPI (Type I)

Provider-specific NPI for billing.

Brand New Providers

Providers new to medical careers requiring extensive documentation

Attestation Questions

Queries regarding provider's history, requiring detailed explanations if needed

Identify the Payers

Recognize entities responsible for payment, crucial for successful credentialing

Timelines and Deadlines

Specific timeframes for completing credentialing tasks, avoiding delays

Retroactive Billing

Submitting claims before credentialing completion.

NPPES

System assigning unique identifiers to providers.

PECOS

System supporting Medicare provider enrollment.

Previous Liability Ins

Ten-year history of professional liability insurance

Payer Identification

First step in credentialing, involves identifying insurance companies to contract with and following their specific rules and procedures

NPI Registry

Free directory of active NPI records managed by CMS, crucial for obtaining NPI numbers and updating provider profiles

What Is PECOS?

Explanation of the Provider Enrollment, Chain, and Ownership System for Medicare

Credentialing

Extensive vetting process verifying provider's identity, experience, licensure, and more

CAQH/ProView

National online provider data-collection system for healthcare professionals, updated every 120 days

Group NPI (Type II)

Organizational NPI associated with a TAX ID.

Delegated Credentialing

Payers allow large groups to maintain their own credentialing, ensuring provider standards

Identifying Information

Personal and professional details for identification purposes

Physician Data Center

Platform for verifying provider information, including malpractice claims

Timelines Importance

Understanding and communicating credentialing timelines crucial for setting patient treatment start dates and coordinating billing

NPI Number

Unique identifier for healthcare providers.

Types of Medicare Applications

Various forms for different provider types like institutional, clinics, group practices, and suppliers, each with specific requirements

Success

Achieving successful credentialing outcomes, vital for provider's professional practice

Reassignment of Benefits

Allows third parties to bill for services.

Hospital Affiliations

Approval letter for hospital privileges and type of privileges

BLS and ALS

Basic and Advanced Life Support certifications

NPDB

Database reporting provider practice history.

Scope of Services

Defined range of services a provider can offer.

Billing Information

Details of billing company, remittance address, and tax ID

Work History

Details of employment history post higher education

Practice Information

Details of practice locations, services, contact, and patient demographics

Communication Is Key

Emphasizes the importance of effective communication in the credentialing process

Primary Source Verification

Ensures accuracy of provider information.

Publications

List of published research or medical articles

Medical Records

Location of medical records, whether electronic or paper-based

Credentialing Specialist

Maintains provider's credentials, ensures legal work status, highly organized and detail-oriented

I&A (Identity & Access Management System)

Manages connections between providers and surrogates securely and efficiently

PECOS and I&A Set up

Medicare data system registration for healthcare professionals

PTAN

Medicare-only number for providers.

Revalidations/Recredentialing

Renewing and updating credentials periodically to maintain legal work status

Onboarding Document

Request for provider's basic information like personal details, license info, DEA number, CAQH login, NPI, payer numbers, and preferred credentialing communication method

DEA Number

Required for prescribing medications, includes issue/expiry dates and prescribing details

Physician's Signature

Required signature on applications, with some payers allowing electronic signatures

Consequences

Results of failing to meet credentialing requirements, impacting provider's practice

Peer References

Three non-colleague references with contact information

Enrollment Timeline

Tracks process duration from start to finish, aids in projecting completion dates and monitoring progress


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