Provider Credentialing Overview
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fraud claims, malpractice suits, incorrect/misssing info, unexplained criminal activity, incorrect ink color, outdated signature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
