Network Provider Credentialing

Transcription

1 Network Provider Credentialing January

2 Learning Objectives Upon completion of today s presentation, you should: Be familiar with the TRICARE certification and TRICARE credentialing processes. Understand what it means to be a TRICARE network provider. Locate online resources, including the Council for Affordable Quality Healthcare (CAQH ) online system and the Provider Information Form. 2

3 About TRICARE TRICARE is the health care program supporting active duty service members, National Guard and Reserve members, retirees, family members, survivors and certain former spouses worldwide. a network of military and civilian health care professionals working together to foster, protect, sustain and restore health for those entrusted to their care. 3

4 TRICARE North Region Health Net Federal Services, LLC (HNFS) is honored to continue our service to approximately 2.8 million beneficiaries in the TRICARE North Region. We thank you for caring for and supporting our nation s heroes. 4

5 Provider Types Network Provider (contract) Authorized Provider (TRICARE-approved) Non-Network Provider (no contract) Non-Authorized Provider TRICARE cannot pay signs prime contractor agreement participating (accepts assignment, i.e., TRICARE payment in full) non-participating (does not accept assignment or TRICARE payment in full) accepts TRICARE negotiated payment files claim for member participates on case-by-case basis files claim for member may file claim for member (if not, member must file) may balance bill up to 115% of TRICARE allowable charge may not balance bill 5

6 TRICARE Certification TRICARE only reimburses TRICARE-authorized providers (also referred to as TRICARE-certified providers). In many cases, providers can see TRICARE patients and file claims with TRICARE to initiate the certification process. Certified providers must meet TRICARE licensing and certification standards and must comply with regulations specific to their health care areas. Certified providers are considered non-network TRICARE-authorized providers, unless they become TRICARE network providers. 6

7 Credentialed Provider Credentialed providers sign an agreement and become members of the TRICARE Prime network. Credentialing involves, but is not limited to, a review of: education board certification license professional background professional liability insurance malpractice history 7

8 What is a network provider? A TRICARE network provider is a credentialed civilian provider who has signed an agreement with HNFS or Managed Health Network (MHN) to be part of the network of providers who participate in the TRICARE program. 8

9 The Role of a Network Provider Serve an important role in TRICARE by complementing the services offered by military treatment facilities (MTFs). Typically receive higher TRICARE patient volume than nonnetwork providers. Agree to a negotiated rate as payment in full for services rendered. 9

10 Primary Care Managers Primary care manager (PCM) network providers must also: provide 24-hour medical coverage and agree to refer health plan members for specialty care, when necessary. 10

11 Starting the Process You must have a network agreement on file with HNFS to begin the credentialing process. Medical/surgical providers who are interested in becoming network providers may contact HNFS at TRICARE ( ) to obtain a contracting packet. 11

12 CAQH Health Net Federal Services is a full participant in the Council for Affordable Quality Healthcare (CAQH ) Universal Credentialing Datasource (UCD) initiative. Visit This online tool streamlines the credentialing process for individual network providers. There is no cost to submit an application and participate with CAQH. 12

13 CAQH It is a requirement to use CAQH to join our network. If you do not have a CAQH number, visit to register each provider with their own file/record with CAQH. There is no cost to providers for registering. A Credentialing POC or Office Manager can register as the Practice Manager and become the POC for all providers with the group. Please keep your CAQH file current it is the biggest delay in the credentialing process and will cause the credentialing to discontinue. 13

14 Provider Information Form In addition to the CAQH application, TRICARE network applicants must also submit a supplemental Provider Information Form,* found on > Provider > Provider Forms and also included in all contract packets mailed to providers requesting new agreements. Fax to our centralized fax number at The Provider Information Form includes information unique to TRICARE that is not addressed within the CAQH application. * Does not apply to TRICARE Standard provider applicants 14

15 How long is the process? The full credentialing process may take days from the time we receive a complete application. When the credentialing process is complete, you will receive written ( or mail) notification from HNFS of the results. If you are approved for TRICARE network participation, we will send a fully executed copy of your participation agreement. 15

16 Adding Providers to Your Group CAQH makes adding providers to your network group quick and easy. New members of your group can update their CAQH profile and submit a PIF to HNFS. If your new group member is not registered with CAQH, visit CAQH s website and register the provider, then submit a PIF. 16

17 Behavioral Health Networks What are the requirements for behavioral health network providers? While medical/surgical network providers are contracted through HNFS, most behavioral health network providers are contracted through MHN. Behavioral health providers should visit and click on Provider Site for more information about behavioral health network provider contracting. 17

18 Keystone Peer Review Keystone Peer Review Organization, Inc. (KePRO) is the quality monitoring contactor for TRICARE. The following facilities must first become certified by KePRO before completing the network provider contracting process with MHN. behavioral health freestanding partial hospital programs residential treatment centers substance use disorder rehabilitation facilities Contact KePRO at or 18

19 Credentials Review Health Net Federal Services conducts a credentials review on each network provider to determine if the provider meets the minimum requirements of the Defense Health Agency, HNFS and URAC. A full re-credentialing review of all contracted health care providers is conducted every three years. HNFS retains the right to terminate any provider contract. 19

20 Specialty Updates There may be times between credentialing cycles when it is appropriate to add, change or delete a specialty description as represented in the Network Provider Directory. These specialty updates can be requested online.* Health Net Federal Services Credentialing Department will review and process all requests received. *Registration on is required. 20

21 Provider Demographics Update Form The Provider Demographics Update Form is an interactive PDF that allows network providers to update: practice address HIPAA-compliant referral and authorization fax number tax identification number billing address main point-of-contact address You may also: add a location delete a location delete a practitioner Keeping your information current allows us to provide the most up-to-date information in our Network Provider Directory. Go to > I m a Provider > Forms 21

22 Additional Information Much of the information provided today can be found on our website, visit 22

23 Online Provider Education TRICARE North Region Provider Handbook Paperless and available at Webinars Live briefings offered every other week. Recorded briefings and downloadable presentations also available. Online tools tutorial A step-by-step guide to online authorization and referral tools. Go to > I m a Provider > Education. 23

24 Questions and Answers 24