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CREDENTIALING

Accreditation is the foundation for quality standards and practice. Our team has experience with HQAA and The Joint Commission. We are familiar with their requirements, standards, survey outlines and have the tools / experience to adequately prepare our clients for success the first time and/or for re-accreditation.

VALUE PROPOSITION

Credentialing and Enrollment Services

With our diligent credentialing and enrollment services, you get the following benefits:

• Get credentialed faster with all significant payors.

• Reduce claim denials and improve cash flow.

• Get more patient referrals from the network.

• Avoid piles of paperwork with our document management system.

• Get support for filling up cumbersome application forms.

• Reduce costs of the credentialing process with our global delivery teams.

• Get timely reports on the status of your applications.

Provider Credentialing and Enrollment Services

Physicians/providers must credential themselves, i.e., enroll and attest with the payor’s network and become authorized to provide services to patients who are members of the payor’s plans. The credentialing process validates that a physician meets standards for delivering clinical care, wherein the payor verifies the physician’s education, license, experience, certifications, affiliations, malpractice, any adverse clinical occurrences, and training.

Payors may delay or refuse payments to physicians who are not credentialed and enrolled with them. These impact the financials of the practice negatively. Our customized payor credentialing and enrollment services support physicians in:

• Starting or joining a new practice.

• Switching from one physician practice group to another.

• Join or become affiliated to new groups or practices.

• Enroll with new payors.

• Maintain their credentialing services.

OUR CREDENTIALING PROCESS

Collect all the data and documents required for filing credentialing applications from the physicians.

• Store the documents centrally on our secure document management systems.

• Understand the top payers to which the practice sends claim and initiate contact with the payors.

• Apply the payer-specific formats after a due audit.

• Timely follow-up with the payor to track application status.

• Obtain the enrollment number from the payor and communicate the state of the application to the physician.

• Periodic updates of the document library for credentialing purposes.

What are the timeframe requirements for credentialing:

Providers have between 30 and 90 days after the day of service to submit a claim, depending on state and payor.  Payors then have 90 - 120 days to pay on that claim. If the claim is rejected and then resubmitted, the waiting period starts all over again. But the payors 90- day clock does not reset if a claim is denied.

Providers could be faced with timely filing issues if they see patients when they are not credentialed properly with payors. The payors will not process claims that occur when the provider is not credentialed. Time can easily run out, and the provider will never be paid for work.

CAQH Attestation:

Council for Affordable Quality Healthcare, Inc. eliminates redundant and inefficient administrative processes between health plans and providers for credentialing, directory maintenance, coordination of benefits, and other essential business functions.

• CAQH application filing

• CAQH quarterly attestations

Expirations and Renewals:

• The tracking expiry date for State DEA License, Board certificate, and Malpractice Insurance

Tracking and Analytics:

• Maintaining a repository of provider’s credentialing documents.

• Maintaining contracting agreements.

• Tracking credentialing dates, expiration, and alerting dates to initiate the credentialing process.

• Working with the denials team to understand if there are any claim denials due to credentialing challenges.

New Registrations/Renewals of an Individual Provider:

• With the State

• With the Drug Enforcement Agency (DEA)

Provider Data Maintenance - Update Management on Payor Systems:​

• Provider demographic update in payors file. (Updates of Provider’s specialty or additional educational qualifications.

• Provider directory maintenance on payer websites. (Checking payor website and verifying provider details like Phone and Fax #, Zip code. Updating the correction to payors).

• EFT/ERA enrollments

Contract Creation (and) Maintenance:

• New Group/Individual Practitioner contracts

• Adding / Deleting providers in the existing contract

• Adding/Deleting location in the current contract