Credentialing specialist chapter 2

Medicare allows providers to apply for their PTAN

60 days prior to their desired effective date and will allow an effective date 30 days prior to the enrollment submission date. Medicare will allow you to select an effective date anywhere in that date range.

There are 3 types of roles within PECOS with are identified through I&A

Authorized Official (IO)-This person can add the employer to the profile, manage staff for the employer, manage connections for the employer, and approve access managers for the employer. Most authorized officials will be the physicians on the executive board who are able to sign documents on behalf of the company or the administrator/CEO of the group. Access Manager(AM)-This person can add an employer to the profile, manage staff for the employer, and manage connections for the employer in I&A. An authorized official can delegate another managing employee to sign documents on behalf of the company pertaining to enrollment. This person is usually the business manager or the credentialing manager of the group. Staff end user: this person may view their employer information, view connections for their employer in I&A, and may be granted access to PECOS and NPPES. This user is usually the credentialing specialist role, as they help to fill out the application but have no signing capability.

All paper applications can be located on

CMS website

Medicare/Provider-Enrollment-and-Certification/Enrollment-applications (you should always download the latest version of paper enrollment application)

CMS-855A-Institutional Provider CMS-855B- Clinics, Group Practices, and Certain other suppliers CMS-855I-Physicians and Non-Physician Practitioners CMS-855R-Reassignment of Medicare Benefits CMS-855O-for ordering and certifying physicians and non-physician Practitioners CMS-855S for DMEPOS Suppliers CMS-20134 for MDPP Suppliers

The following are some suggestions of the type of information you will need to include in your credentialing calendar which will help you to track the status of your enrollments.

Contact info(phone or email) for the payer, submission method (call or email, or online, or mail), date of submission, date it was confirmed as received by the payers and contract effective date. Leaving room for notes is also important so you can include additional details such as contact info for the specific individuals at the payer, follow up tracking and status, and length of time enrollment takes from start to finish.

Commercial Insurance Payer Credentialing

Each commercial payer will have their own requirements and process for credentialing submission. Some payers will have online portals for you to submit the credentialing applications. While others will require a form to be filled out and emailed, or faxed into the credentialing department.

The following forms are routinely submitted with an enrollment applications

Electronic funds transfer EFT Authorization agreement from CMS-588 Medicare Participating Physician supplier agreement form CMS-460

Medicaid Credentialing

Enrollment and credentialing process for Medicaid practitioners and suppliers are designed to: Protect Medicaid beneficiaries from receiving care or services from providers who are unqualified Prevent improper payment for services rendered by providers who do not meet federal and state requirements for participation in Medicaid Programs.

Walk through the process of adding a provider to an existing group enrollment

First click on my Associates to view the list of the providers associated to you via the I&A management system. You will first want to review the provider's active enrollments and verify the accuracy of the existing group enrollment. If there is an active enrollment with another organization, then a reassignment of benefits or 855-R is the application is required. The provider will need to reassign their benefits for any claims that are submitted under the group NPI. You should not perform initial enrollment for a provider who is already enrolled. . The active enrollment should be updated, not terminated. If, upon review, there were no active enrollments for the provider the next step would be to create an initial enrollment or 855-I.

to submit an application via PECOS

First you are required to have a login through the identity and access I&A management system. There are different users associated with the I&A system. Each user will have their own specific credentials to access the system, and credentials should not be shared among users. The provider, group, and employee will have their own long in to this system.

Payer credentialing process

Includes but not limited to requesting participation in a payer network, completing credentialing requirements, submitting provider and group documents to the payer, and the execution of a contract (if your group does not have a current executed contract on file).

CMS-20134

Is for Medicare Diabetes Prevention Program (MDPP) suppliers. They must be enrolled for any organization wishing to furnish diabetes prevention and care maintenance services.

CMS 855S

Is for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) Suppliers must have this application completed to enroll each physician location used to furnish Medicare-covered DMPEPOS to Medicare beneficiaries, except for locations only used as warehouses or repair facilities.

CMS-855A

Is for institutional providers. Complete this application for healthcare organizations that plan to bill Medicare Part A (covers inpatient hospital stays, care in skilled nursing facilities, hospice services, and home health care) or would like to report a change to their existing Part A enrollment. The following healthcare organizations must complete this application to initiate the enrollment process. Community mental health centers Comprehensive outpatient rehab facility Critical access hospital End-stage renal disease facility Federally qualified health center Histocompatibility Laboratory Home health agency Hospice Hospital Indian health service facility Organ procurement organization Outpatient physician therapy/occupational therapy/speech pathology services. Religious non-medical healthcare institution Rural health clinic Skilled nursing facility

CMS-855I

Is for physicians and non-physician practitioners (NPPs). Complete this application for individual providers who plan to bill Medicare and are Individual practitioners who will provide services in a group setting. If you plan to render all your services in a group setting. If you plan to render all your services in a group setting, you will complete sections 1-4 and skip to sections 14 through 17 for this application Currently enrolled with Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor jurisdiction. (you have opened a practice location in a geographic territory serviced by another fee-for-service contractor). Currently enrolled in Medicare and need to make changes to your enrollment info (you have added or changed practice location) An individual who has formed a professional corp, professional association, or limited liability company of which you are a sole owner. If you provide services in a group/organization setting, you will need to complete a separate application the CMS 855R to reassign your benefits to each organization. Providers must complete if Anesthesiology assistant. Audiologist Certified nurse midwife Certified registered nurse anesthetist Clinical nurse specialist Clinical social worker Mass immunization roster biller NP Occupational therapist in private practice PT in private practice PA Clinical Psychologist Psychologist billing independently Registered nutritionist or dietitian Speech path.

CMS-855R

Is for reassignment of Medicare benefits. Complete this application for providers who need to reassign their right to bill Medicare program and receive Medicare part B payment for an eligible individual, clinic, group practice, or other healthcare orgs. Reassigning Medicare benefits allows the eligible suppliers to submit claims and receive payments from Medicare part B services by the individual provider. Things to consider: Both the individual practitioner and the eligible supplier must be currently enrolled (or concurrently enrolling via submission of CMS855B for eligible supplier and CMS855I for the practitioner) in the Medicare program before the reassignment can take effect. Generally, this application is completed by a supplier signed by the individual practitioner may submit this application with the appropriate sections completed. This individual or authorized/delegated official, by his/her signature, agrees to notify the Medicare fee-for service contractor of any future changes in the assignment in accordance with 42 CFR An individual will not need to reassign benefits to a corporation, LLC, Professional associate etc. of which they are the sole owner. See the CMS 855I for more info.

PECOS pre -application questions to determine which enrollment application is needed.

Listed below are the standard options to choose from. Please ensure you have a full understanding of each option to categorize the enrollment. 1. Sole owner of a PA, PC or LLC (individual owner of the practice) 2. Self-employed (does not work for a large organization. works for themselves only) 3. Group members and self-employed (works for oneself, but also an employee of the group practice) 4. Disregarded entity (an entity otherwise not recognized). For example-If you are enrolling a provider with your group who is employed by your group with no ownership stake-then the provider will be a group member only. At this point, you will be prompted to fill out the applicant's name, Social Security number, and date of birth, followed by the state/territory where the applicant renders healthcare services. This info request then will be followed by choosing the provider specialty and the system will ask about the reassignment of benefits.

CMS-460

Medicare-participating physician or supplier agreement to accept assignment for all covered services provided to Medicare patients. You can submit either within 90 days of the initial enrollment or during the annual open enrollment period (typically Mid-November through December 31), If you are a provider joining a group who already participates with Medicare, whether you participate with Medicare or not, by joining a group practice who participates, you become a participating provider.

Creating the Enrollment to PECOS

Once all the connections have been made through I&A, you can begin the application through PECOS.

Ready to submit

Once you have submitted the Medicare enrollment, PECOS gives you the opportunity to print the submission confirmation page, which indicates the date of your submission and the tracking information. Make sure to print and save a copy of this page for your records for tracking purposes and in case you ever need to prove submission details.

To show reassignment or employment arrangement,

PA will still complete Section 21 of the CMS-855I.

What is PECOS

PECOS is where you will submit the electronic application for Medicare participation. PECOS has each of the previously described forms in electronic format and will walk you through a step-by step process to complete. There are instructional videos and guides to assist you in submitting the application online.

PA payments/Medicare enrollments

Prior to Jan 2022, only PA's employers could receive the payment. Now PAs can individually enroll in Medicare (sole practitioner or pro corp.). They can receive direct payment for his/her services. They can establish PA groups (LLC), they can reassign their benefits to the employer.

To obtain Medicaid provider ID number

Provider enrollment and credentialing are needed to be obtained.

Information that is available through the NIPPES NPI Registry is

Provider's name, gender, NPI number, Practice mailing address, primary practice address, and secondary practice address, as well as phone , fax, health information exchange and other identifiers, and taxonomy code info.

If PA will not be reassigning their benefits and will be individually enrolling and/or establishing a PA group.

Section 21 of the CMS-855I will not be required.

What do you do after receiving all of the necessary info.

Start the credentialing process by creating a spreadsheet that lists the pertinent credentialing details collected from the provider (Full name, other used names, date of birth, place of birth, SSN, NPI, DEA, State license number, and all applicable expiration dates. Obtaining the group type II NPI, tax ID, group name, group demographics info and all existing payer group numbers such as Medicare provider transaction access numbers (PTANs) is also important.

CMS-588

This is an electronic funds transfer EFT authorization agreement, which allows the group or the provider to receive their Medicare claim payments directly from Medicare to a provider or group's bank account through direct deposit. CMS requires that all providers enrolling or changing existing enrollment info to maintain the most up-to-date EFT information. The EFT form may be submitted online through PECOS or downloaded from the CMS website. The form must be completed an accurate, and must include the original or electronic signature of the authorized/delegated official .

If you experience any delays in the processing of the enrollment (missing signatures, incomplete application, lack of required documentation etc.)

This may affect your effective date for the provider. It is not advisable for the provider to see Medicare patients before their effective date has been confirmed.

Tracking information will help

This will help the team track and determine projected timeline/completion dates in the future and how errors, barriers, and delays in the process were handled.

True or False. Commercial payers have separate credentialing rules from Medicare, Medicaid, Tricare,VA

True

True or False. Payers will not reimburse a provider or group for services rendered by a provider who is not a credentialed and contracted provider of a payer's network.

True.

True or False Understanding how each payer with which you are credentialing the provider grants effective dates is vital

True. It can very from the date the credentialing is submitted, the date that the credentialing approved, the date that the provider is loaded, the date that the payer's directory is updated or the execution signature date of the group's contract.

True or False. Nearly all states have some form of managed care plan in place, comprehensive risk-based managed care/and or primary care case management (PCCM) programs.

True. Medicaid managed care organizations MCOs provider comprehensive acute care, in some cases, long-term services to Medicaid beneficiaries and are paid a set-per member , per-month payment for these services.

CMS provides oversight, while states

administer the Medicaid program.

Some states are using CAQH to

aid in their Medicaid enrollment. The select Medicaid payers that are using CAQH are an exception to the rule.

Unless a special situation arises

all efforts should be made to submit application through PECOS and not via paper application. PECOS is faster, more secure and easier to track.

Mismanagement of the credentialing process will cause

burden on the group's billing and administrative teams as the practice will not be able to submit the provider's claims until the provider has been approved.

When you seek a contract with an insurance payer it is a requirement to

credential all providers.

How often should you perform CAQH maintenance, review and attestation renewal

every 3 month. That ensures that the provider's CAQH profile is accessible to payers that subscribe to the service and that all provider info and documentation is current. The maintenance date for the provider's CAQH profile will depend on the date it was initially completed.

CMS-855B

for clinics, group practices, and certain other suppliers. Complete this application for a medical group or clinic that will bill Medicare part B (covers certain doctor's services, outpatient care, medical supplies, and preventative services), a hospital or other medical practice that may bill for Part A services but will also bill for Part B provider services or provider-purchased laboratory tests to other entities that bill Medicare part B, are currently enrolled with Medicare fee for service (FFS) contractor, but need to enroll in another FFS contractor's jurisdiction, or currently enrolled in Medicare and need to make changes to their enrollment data. The following supplier must complete this application to initiate enrollment process. Ambulance services supplier Ambulatory Surgical Center Clinic/group practice Hospital departments Independent clinical lab Independent diagnostic testing facility (IDTF) Intensive cardiac rehab Mammography center Mass immunization (roster billed only) Pharmacy Physical/occupational therapy group in private practice Portable X-ray supplier Radiation therapy center

Knowing how to obtain an NPI number is an

important step for credentialing any provider.

The NPI Registry public search

is a free directory for all active NPI records. It is a federal government website managed by the CMS.

A roster

is a list of active rendering providers within a group. Roster requirements will depend on the payer but should include info similar to the items in your credentialing spreadsheet.

CMS-855O

is for ordering and certifying physicians and non-physician practitioners. CMS requires certain physicians and NPs to register in the Medicare program for the sole purpose of ordering and referring services for Medicare beneficiaries. These physicians and NPPs DO NOT AND WILL NOT send claims to Medicare.

Having open communication between the credentialing specialist and admirative and billing teams

is important to coordinate the scheduling of patients and ability to submit claims.

Contacting the payer's provider relations department

is the most effective way to obtain instructions on how the payer wants credentialing application submitted.

Payer credentialing or enrollment

is the process of a provider becoming contracted with insurance payers. This may also be referred as the provider becoming in network.

The Medicare Provider Enrollment. Chain and Ownership System PECOS

is used to facilitate electronic submission of application rather than mailing the paper application. Mailing the provider's application takes significantly longer than submitting the credentialing application through the PECOS system. PECOS is online Medicare enrollment management system which allows you to Enroll as a Medicare provider or supplier Review information currently on file. Upload your support documents Electronically sign an submit your information online Revalidate the provider's info on a cycle that is standardized every 5 years.

If a form is required for a commercial payer

it is important to ensure that you have the most up-to-date credentialing application on hand.

The NPPES website provides details on how to

obtain an NPI and instructions for updating the existing profile associated with the NPI

Medicare has different applications and requirements depending

on the type of provider you are credentialing .

MCOs contract with private insurance companies to

provide Medicaid benefits on behalf of the state.

The provider's effective date to start at the group

relies on the credentialing team and their efficiency with the process.

The Medicaid Managed Care providers must be

screened and enrolled with the state to be considered in network and becoming in network may require you to execute a provider agreement with the state. Some states have created an "MCO-only" provider type and separate enrollment process.

Providers use their Medicaid numbers to

submit claims for services and receive reimbursement from the Medicaid program. States determine how they will deliver and pay for care for Medicaid beneficiaries.

Making the Surrogacy Connection

the AO or AM will make the surrogacy request to work on behalf of the provider in the PECOS system. Once the access has been accepted, the AO or AM will also need to grant the employee or staff end user (credentialing specialist) access to work on behalf of the group on behalf of the provider. It is important to have access not only to PECOS but to NPPES, as this will allow you to update the NPI Registry information, and maintenance of this registry is vital to the success of the overall process.

Individuals (type I) and organizations (type II) apply for NPI through

the CMS National Plan and Provider Enumeration System (NPPES).

Once CAQH has been updated, attested to , and permission is granted by the provider for each payer to view

the insurance company will access the provider's credentialing info and their supporting documents.

If the provider has an existing CAQH profile

then it will need to be reviewed and updated to include the group's information.

There are several options when you are completing the application

to either click on each section and review or to go to a fast track to review what Medicare recommends you to review. The best practice until you are familiar with the process is to complete each section in order listed. If this is a new provider to your group, you will need to go through each section to ensure correct correspondence information, license, contact personnel and group details to establish reassignment. You will need to ensure that all documents requiring wet signature are complete and available to attach to the application via the file upload prompt or you may be given the ability to have the documents electronically sent to the authorized or delegated officials for final signature approval of the enrollment.

The first step in payer credentialing is

to identify the payers which you need to credential the provider.

States have traditionally used managed care models

to increase budget predictability, constrain Medicaid spending, and improve access to care and value.

All new providers who are transferring from another practice

will be required to update the info on file.

Which type of user you are

will dictate the amount of access you have

Understanding the timeline and process it takes to successfully credential a provider, as well as communicating this information to all teams

will set clear expectations as to the start date of when the provider can start treating patients. As a credentialing specialist you will want to be honest and transparent with the expectations for each payer's process with the provider.

Most of the commercial payers

will use national online credentialing database called CAQH. As noted before, a provider's CAQH number username and password should be collected during an onboarding.

Once you have identified all the payers with which you need to credential your new provider.

you should create another document that contains the names of the payers that you will be working with during the process.

There are some payers that will allow

you to submit an updated provider roster instead of an application and the payer will provide you with spreadsheet to complete.

After enrollment is submitted you can get a real-time updates on your application and

you will be contacted directly if errors are found with instructions on how to fix them.

Finally

you will either receive a return letter via email to correct errors or you will receive a confirmation of the PTAN number assigned to the provider. All will be communicated via email, so it is important to ensure the correct contact information on the enrollment prior to the submission.

If the provider has already started practicing with the group

you will want to ensure