CC Services Explainer

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.

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Type 1: Individual NPI – Type 1 NPI issued to individual providers.

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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.

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Doing Business As: If applicable as needed.

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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.

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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.

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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.

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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

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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 6. CLEARINGHOUSE (CHANGE, TRIZETTO, WAYSTAR...THERE’S A BUNCH) 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.

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DO’S AND DON’TS!

DO’S

DON’TS

✓ Have your information ready to submit...all of it! ✓ Have your supporting documents available and ready (and current). ✓ Plan ahead - 3-6 months MINIMUM for contracting and credentialing alone.

× Use personal information to apply in business contact fields such as address/contact phone. × Username/password share between staff members for portals. × Expect to be able to use “incident-to” or “locum tenans” billing to end around timelines - fraud is a thing folks and they’re looking for it.

✓ Plan for additional time for licensing. ✓ Set the business owner as the primary contact.

We love our staff and never want to lose them, but people change jobs. You’ll have to update your contact every time. ✓ Expect provider changes, identifier changes, name changes, location changes, payer additions/removals to take MONTHS to update (remember to plan ahead). ✓ Expect to re-credential every year to two years per payer and per facility privileges. ✓ Be sure to request a Contract Grid including which payers and networks you accept per provider.

× Delay on information gathering/sharing.

Processing timelines don’t start until you send all requested information in correctly formatted. × Use a Doing Business As (DBA) without having it listed on your legal documentation (e.g., CP575). × Expect contract negotiations to be allowed, easy or reasonable. This is extremely difficult these days and the payers delay the process to force you into taking bad rates. Geographic region and specialty will impact this process as well. × Delay in telling your team about upcoming practice changes (e.g., provider, location, payer).

✓ Be sure to request fee schedules. ✓ Pay attention to timely filing deadlines. ✓ Pay attention to Clinical Integration and MACRA/MIPS requirements ✓ Research delegated contract models from local MSO, PHO, ACO, CIN etc. (better rates folks).

× Start adding contracts to your grid because 1-3 patients showed up at your front desk with a new insurance card. Be strategic about your contracts.

✓ Call us if you are unsure of what to provide, let’s meet to discuss!

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CREDENTIALING CONTRACTING WORKFLOW MAP Document Collection: Provider Timeline Portal Review - 24 48 Hour Turn Around Time (TAT)

TAT 48 Hours to Contact, 1-2 Weeks for Full Responses

TAT 2-5 Business Days

TAT 2-5 Business Days

Provider Documents and Portal Validation

Credentialing and Contracting Scope Research

Application Submissions to Payers

Confirming the Receipt of Application in Insurance

1. Documents

1. We confirm providers need both Credentialing and Contracting process versus just Contracting if the provider already has active Credentialing under the proper identifiers (e.g., GNPI/EIN).

2. State License 3. DEA 4. Malpractice Insurance Coverage 5. CP575

2. Contact Payers to collect data points and verify ETA.

6. CV 7. Voided CK

Calls: 30-90 minutes

9. Portals

Emails: 15 minutes per email

10. CAQH Preview - Review/Setup

Average # Calls 3 Average # Emails 3

12. Availity Review/Set Up

Normal Process Time = 1-2 hours/payer

13. Optum - Review/Set Up

1. Via insurance portals/websites.

2. Through Fax/E-mail/Mail.

Medicare – 45 Minutes.

Aetna – 30 Minutes.

BCBS – 45 Minutes Medicaid – 1 hour

8. NPI Registration

11. NPPES - Review

We submit the applications.

Other Commercial (Cigna, UHC, Humana + ??) - 45 -1:30 per application Normal processing time for a standard practice with Big 5 Payers (e.g. Aetna, BCBS, Cigna, Humana, UHC) and Medicare/ Medicaid = 7.5 hours

Calling the knuckleheads to be sure they have it on file and are processing everything we sent them.

Calls: 30-90 minutes Emails: 15 minutes per email Average # Calls 6 Average # Emails 12 Total time spent: 9 hrs calling and 2.5 hrs emailing per contract.

54 hours calling and 22.5 emailing for Big 5 + CMS

TAT 24 hours

Provider Timeline Dependent

48-72 hours

Biweekly F/U...bang head in same spot on wall

Payer Contract Processing

Awaiting Provider Signature

Auctus Contract Review

Insurance Follow Up

We review the assigned rate with reference to CMS (Medicare) as a baseline rate to be sure it is acceptable for the specialty and geographic region. We ensure the proper networks (e.g., PPO + Medicare Replacement + etc.). We review timely filing, clinical integration etc.

30-60 minutes per contract 7 hours

More head-banging...for months

Days to Weeks depending on payer

TAT 24 hours

Insurance Follow Up

Counter Offer Signed and Fee Schedule from Insurance Received

Sending Insurance Signed Contract and Fee Schedule to Provider Office

Contracting standard processing time is 45-60 days, but it can draaaaaag...like 3+ months. We follow up weekly/biweekly.

We log contract and fee schedule, add to grid for client and mark contract as finalized!

Calls/Emails - 15 mins/45 mins to 1 hour follow required.

TAT 1-4 Weeks (usually)

WHAT TO EXPECT ON RATES? Aetna – 70-95 % of CMS

3 calls/3 hours and 3 emails/45 min per contract

Hold Claims for Contract Load Date

26 hours and 15 minutes Total Time

Cigna -70 -100 % of CMS. BCBS - 65%- 135 % of CMS UHC- 85-110 % of CMS. Delegates - 10-50% increase Carve Outs - Procedure and will vary based on geographic region, specialty and direct versus delegated contracts

Yes, even once everything is signed, it takes payers time to upload the contract into their system so they can actually process claims and/or update your provider portal on their website. Send a few test claims first.

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CREDENTIALING CHECKLIST Please complete all pages and all attachments requested. All documents should be scanned as individual documents. Do not provide attachments as a single multi-page document or send cell phone jpg files.

Please indicate anything that is not currently in place by leaving it blank or marking “not available.” This will become a “to-do list” for us to follow up on.

PERSONAL INFORMATION Provider’s Name

Date of Birth

Social Security #

City & State of Birth

Home Address Cell Number

Email Address LICENSE AND REGISTRATION INFORMATION

License #/Issuing State Additional State/Licenses CDS Number (if applicable)

DEA Number Medicare ID/UPIN #

BUSINESS INFORMATION - FOR THOSE STARTING THEIR OWN PRACTICES ONLY Entity Name Tax ID # Practice Name Practice Address Pay to Address Practice Phone

Practice Fax #

Practice Email

Personal Email

Malpractice Account # (New entity only) INSURANCE PARTICIPATION I am currently participating with insurance plans in the state my private pactice will be located.

I am not currently participating with insurance plans in the state my private pactice will be located.

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WEBSITE INFORMATION Please list any websites that you are currently listed with as a provider.

DOCUMENTS TO BE PROVIDED When Scanning documents please scan and save each document individually not as multiple pages.

Anticipated State Date with the practice: National Provider Identifier (NPI) - Website: https://nppes.cms.hhs.gov/#/ NPI Number: GROUP NPI Number for new practice (if you don’t have one, credentialing can assist) (OFFICE WILL COMPLETE THIS): CAQH Information (CAQH must be up to date) - Web site: http://www.caqh.org/solutions/caqh-proview If you need assistance, you may contract CAQH at 888-599-1771 Mon-Thurs 7am-9pm ET and Fri 7am-7pm ET Provider ID Number: User Name: Password: Clear legible copies of the following documents: NPPES Confirmation letter/email showing NPI Number and Taxonomy assigned Social Security card Drivers License and/or Passport Medical school diploma and other training diplomas State Medical License (Cannot be credentialed unless license is in place in state you will be practicing in) DEA and/or CDS Registration Certificate of Professional Liability Insurance-include evidence of surcharge for Mcare better know as CAT Fund Board Certifications (if board certified) Curriculum Vitae (must reflect month/day/year in all categories) Education Internship Residency Experience

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DOCUMENTS TO BE PROVIDED NCCPA Certification (Physician Assistant only) Supervising Physician and Collaborative Agreement AANP Certification (Nurse Practitioner only) If in PA - Pennsylvania State Board of Nursing Application for Prescriptive Authority (Nurse Practitioner only) Practice Collaborative Agreement (Nurse Practitioner only) Documents regarding all settled, dismissed and/or pending malpractice claims.

If you have other practices/organizations and you will continue to reassign your Medicare payments to please provide: Name of Group/Organization and their Medicare ID number and NPI Info from current/any previous practices (This is important or your payments could be affected) Tax ID# Group NPI# List of insurances you are currently participating with – note any that you do not wish to continue with Any provider ID# associated with your plans MALPRACTICE INFORMATION Credentialing cannot take place without a malpractice face sheet for our practice. We will need several items to get this process rolling and will assist you in any way that we can.

DO NOT HOLD UP RETURNING THIS FORM OR OTHER DOCUMENTS AS WE CAN GET STARTED WITHOUT THE FACE SHEET. Will you be working under 25 hours per week for our practice?

Do you have any malpractice claims?

IF yes, you will need to provide a narrative of the case and it’s disposition (settled, pending etc).

If applicable, please notify Kathleen Adams and attach the narrative.

Do you have any disciplinary action against your medical license?

IF yes, you will need to provide a narrative of the case and it’s disposition (settled, pending etc).

If applicable, please attach the narrative.

Please contact any malpractice carriers you have had in the last 10 years post residency. Contact the carrier directly and request a claims history or abstract. Even if you do not have any claims, the new malpractice carrier will need a “clean history” document to obtain coverage for you.

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CURRENT/PREVIOUS INSURANCE PLANS Add names of all current insurance participation and check if wish to continue/ discontinue association under new practice if offered in the state. Additional local plans may be suggested/ added based on new location.

Current Insurance Participation PLAN NAME

Wish to Par with in New Practice STATE VERSION OF PLAN (HMO/PPO)

Discontinue Par in New Practice STATE VERSION OF PLAN

Comments / Notes:

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