PROVIDER CREDENTIALING & CONTRACTING CHECKLIST
Credentialing and Contracting (CCServices) is important for all in-network providers, but they are often not familiar with the pain-the-in-arse process, nor documentation required for said pain-in-the-arse process. The abundance of payers, forms, and online portals (versus paper forms with redundant fields and obscure questions) and we know this is a run on sentence but that is kinda the point. Add the distinct pleasure of calling, emailing and getting bad info, calling again, and emailing again...you see where we’re going with this? CCServices isn’t rocket science, but there’s some dense nuance, the process is not intuitive, and there’s a fair amount of bang-head-in-same-spot-on-wall, which the insurance companies think qualifies as “communication.”
The question is do you really have time for that? We didn’t think so.
So here’s our handy dandy little explainer document to help our providers better understand the process and facilitate expedient processing times!
SO WHAT DO YOU NEED TO GET STARTED?
INFO NEEDED
1. BUSINESS START DATE OR PROVIDER START DATE WITH NEW GROUP
We recommend setting the date 90 days AHEAD of the desired start date to give some breathing room in the event of any payer processing delays. So if you’re actually starting in April, we’re going to call in January.
2. PROVIDER DOB AND SSN
Invasive info, but necessary. We’ll also need home address and cell for setting up portals like CAQH.
3. NPI NUMBER( S )
The Unique number assigned by NPPES for individual providers and the Group. Think of this like a SSN for healthcare providers and/or businesses.
• Type 1: Individual NPI – Type 1 NPI issued to individual providers.
• Type 2: Group or Organization – Type 2 NPI issued to Groups, Facilities and Hospitals.
4. GROUP DETAILS
• Legal Business Name: The name should be printed in your IRS CP575 document...the one they sent your attorney or CPA when you first filed for a Tax ID number that you’ve never looked at again...yeah that one.
• Doing Business As: If applicable as needed.
• Tax ID (TIN)/Employer Identification Number (EIN): Yes, they are one and the same. Individual providers can use their SSN in lieu of their TIN/EIN, but we DO NOT recommend it.
• Practice and Billing Address: You will need your practice address with correct suite number if applicable. No, you cannot use a home address. This needs to be where you intend to practice medicine. You can have a separate Billing/Mailing Address for insurance correspondence which can be a PO Box if you’d like. This information will be on insurance directories and all over the internet so DO NOT fake it ‘til you make it with your buddy’s practice address either...ultimately any “temporary address(es)” will need to be updated and that’s another 30 day+ process with paperwork per payer.
• Group Phone and Fax #: Again, this is going to be all over the interweb. Get a business number even if you don’t need it yet. $2.99/month versus your cell phone number being out there? Easy call.
5. HOSPITAL ADMITTING ARRANGEMENTS
Either by having admitting privileges, using a Hospitalist group, having another provider who admits on your behalf, or referring a patient to ER or PCP, you will need some arrangement typically. This will not be relevant for every specialty of course.
6. PROVIDER CONTACT PHONE AND EMAIL
For internal purposes...you’ll have questions. We’ll have questions. We should talk.
7. EMAIL AND IN OFFICE CONTACT
Use your info or your administrator’s. Keep in mind if you use an admin and you lose an admin you need to update said admin with every payer...
DOCUMENTS NEEDED
1. STATE LICENSE
This one shouldn’t be a surprise. You will indeed need a license to practice medicine in the state in which you intend to render services (caveat here for telehealth, but that is a whole other ball of wax). Don’t have a license? We can help, but add another 60+ days to your timeline. Practicing in multiple states? Consider the Interstate Medical Licensure Compact (IMLCC) where you can obtain licenses in multiple states extremely quickly (like weeks not months) once it is set up. Keep in mind, these IMLCC licenses often have shorter renewal periods (as frequent as annual renewal).
2. DEA
All prescribing providers must have a DEA in each state they intent to or actively prescribe in. You can transfer licenses between states, but they’ll only be active in one at a time. Not sure where to start? We can help. This is NOT required for all specialties and/or if you’re not prescribing medications that would necessitate a DEA.
3. CURRICULUM VITAE (CV)
AKA resume. We’ll need a copy of a CV with education and work history details, including start/stop dates. If the provider has a work history gap more than 90 days, we’ll need to provide a reason/cause/explanation. We use this as a “source of truth” for the majority of the demographics that need to be populated into portals and forms.
4. MALPRACTICE INSURANCE
All providers should have malpractice insurance in force with active coverage, which meets the required limits ($1M per incident and $3M Annual Aggregate). Some states will have small variations such as different limit requirements/allowances and others will want copies of Commercial Liability for the business as well (i.e. CA Medicaid, AZ Molina). We’ll need a copy of your Confirmation of Insurance (COI). Your carriers CAN issue this ahead of the coverage start date to confirm it will be in force by your practice start date.
5. COPY OF DEGREE/DIPLOMA/BOARD CERTIFICATE
Just in case you were faking it...
6. VOIDED CHECK
Yep they need this too. Don’t have checks? Go get a starter from your bank. It’s free. They can print whatever you need on it. Takes 10 minutes. This is required to set up Direct Deposit/Electronic Funds Transfers (EFT) for payment...unless of course you prefer snail mail? Carrier pigeon? We strongly advise all providers enroll. More electronic = more better. This needs to match your CP575 (EIN assignment letter) EXACTLY...like can’t be missing the “.” between the “LL” in your LLC. Seriously.
WEB PORTALS NEEDED
1. CAQH
CAQH is online demographic portal used by most of the major commercial insurance carriers. You will definitively need an account (you probably have an account from residency or your academic/big box employer in the past even if you’ve never logged in yourself). Once you have access, we need to verify that the info is accurate and up to date with all required supporting documents and “validate” every 90 days. “Validation” means confirming the info is up to date with a few quick clicks. They’ll remind you via email, but honestly it will take you about as much time to forward the email as it will to click the button if you’re up to date with your profile info. Don’t have access? No clue where to start? They have reset options online and a looooovely call center.
proview.caqh.org
2. PECOS/NPPES/I&A SYSTEM
Think CAQH, but for Medicare, because it’s the government and they’re special so they need their own. Also, it is three websites, not one...but they all have the same login info...totally not confusing right?
a. I&A System = Managing your login and delegating access to others. nppes.cms.hhs.gov/IAWeb/login.do
b. NPPES = Apply for and manage your NPI info. nppes.cms.hhs.gov
c. PECOS = Apply for Medicare network access. pecos.cms.hhs.gov/pecos/login.do
3. AVAILITY
This portal is a lot of things. It is a Clearinghouse (used to send/receive electronic data like claims and remittance advice to/from payers - see below). It is a profile portal (similar to CAQH). It is a claim status/appeal/eligibility tool portal for major payers like MOST BlueCross/BlueShield (BCBS) carriers in most states as well as Aetna, Humana, etc. There are exceptions here like California, Michigan, North Carolina, Washington etc., which have their own portals in addition to Availity.
All of these tools are important for medical billing processes, but the necessity for CCServices is that many states REQUIRE your BCBS applications be submitted in the portal. So without Availity, you can’t even apply to the network. In order to register for Availity, you’ll need to register an individual and go through identity verification (e.g., what color was your Audi in 2017). If you are a NEW practice, you’ll have to set up your business as well. This can be a several-month process. Availity Security Team (who won’t get on the phone and isn’t always super quick to reply) will request proof of ownership documents like your CP575, Articles of Incorporation etc. Toughest part of this equation...ONLY the user can call in. No account sharing. No one else can discuss the account UNTIL it is set up, at which point you can assign sub-admins who can then help with all this. availity.com/Essentials-Portal-Registration
4. OPTUM
Think Availity, but for United Healthcare Only...oh and clunkier tech. There are modules like Optum Pay (for electronic remittance advice (ERAS), Document Library (they don’t mail anything anymore as a company policy), and much more). Optum is also a clearinghouse, billing tool, profile manager etc. You won’t necessarily need to submit your contract online, but you’ll need access here to communicate with them. Similar set up process of setting a user up and adding your business, but a bit less back/forth here. optum.com/sign-in.html
5. MEDICARE CONTRACTOR PORTAL
This is going to vary based on what region of the country you’re in as Medicare has different contractors who administer their processing/portals per region. Not sure where you fall? Check out the link below. This portal is necessary for medical billing of course, but also important for your electronic data interchange (EDI) enrollments. This is the paperwork that tells the insurance companies what Clearinghouse to send/receive your data (e.g., claims, remittance advice, eligibility checks and so on). For Medicare in particular, there is a second level of validation in the process called EDISS, which is why we need this portal for CCServices. Again, you’ll need to register a user for the portal and can set up sub-admin. Check with your CCServices team about where to enroll as the link will vary per contractor.
cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs
We covered this briefly, but again, think of this as the electronic link between your Practice Management/Billing/ Electronic Medical Record (PM/EMR) system and the insurance companies. Everything (mostly) should be going electronic these days and this is your electronic USPS so to speak. Generally, you don’t get a choice here. Your PM/EMR will have a partnership and the choice is made for you. The price is often rolled into your PM/EMR cost, but may not be so be sure to ask! Sometimes the PM/EMR actually runs the clearinghouse behind the scenes so you scarcely know they are there. Sometimes you’ve got to set the integration up. Sometimes it is a manual process to upload/download data. Point is this is something you want to ask about because you do have those EDI enrollments to do PER PAYER in your Clearinghouse...and it can be a lot. This is also the time to be sure you’re enrolling for Electronic Funds Transfer (EFT) so you’re not getting snail mail checks for your payments.
Generally, these tasks falls on the practice itself or sometimes the billing company helps. Be sure to at least raise the questions of who is handling this so that your bases are covered. This is something we do for our billing clients automatically, but we’re not every billing company so be sure you’re asking! Each Clearinghouse will have their own links and processes - so ask your CCServices/Billing teams if you need clarification.
