Alphabet Soup of Provider Credentialing. Anne Hanzel Alta Partners, LLC
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1 Alphabet Soup of Provider Credentialing Anne Hanzel Alta Partners, LLC
2 Why is Credentialing Important? Patient Safety Build practice base Allow for discounted amounts Direct link to managed care systems
3 Credentialing Timeline In general, the timeline for approval of credentialing applications is days, dependent upon the following: Type of insurance carrier Type of application Type of physician e.g., a physician new to the area, graduating resident or fellow Change in provider status e.g., switching EIN but remaining in same geographical area Consequences to untimely credentialing include Loss of revenue Inability to maintain practice base
4 Credentialing Definitions NPI PTAN CAQH UPD (CAQH) EIN (FEIN) PECOS NPPES National Provider Identifier Provider Transaction Access Number Council for Affordable Quality Healthcare Universal Provider Database Federal Employer Identification Number Federal Tax Identification Number Provider Enrollment, Chain, and Ownership System National Plan & Provider Enumeration System Entity Type 1 Individual Entity Type 2 Organization Unique 10-digit ID number for covered health care providers Issued by National Plan and Provider Enumeration System (NPPES) Medicare-only number issued to providers by Medicare (Medicaid) contractors upon enrollment to Medicare Provider s current legacy number with Medicare Online provider data-collection service Standard electronic form that meets the needs of nearly every health plan, hospital, and other healthcare organization 5 Steps: Registering; Completing the UPD Online Form; Authorizing UPD-participating Plan Access to the information; Verifying data entry/ Attesting; Submitting supporting documentation Unique 9-digit number assigned by the IRS Used for employment tax reporting and Identification (TIN) Electronic Medicare enrollment system Used for initial Medicare enrollment, revalidation, and change in enrollment Administered by CMS System for applying for & receiving NPI Database for searching for an provider s NPI
5 Credentialing Process Tax ID Group NPI Group PTAN (Medicare) Individual PTAN (Medicare) Additional PTAN issued for each state of practice Group PTAN (Medicaid) Individual NPI CAQH Individual PTAN (Medicaid) Additional PTAN issued for each state of practice Group Commercial Insurance Individual Commercial Insurance
6 CAQH Application Personal Information & Professional IDs Education & Training Professional/ Medical Specialty Info Practice Location Information Hospital Affiliations Professional Liability Insurance Carrier Work History & References Disclosure Questions Provider Type Undergraduate School(s) Primary Specialty Primary Practice Location Admitting Arrangements Current Military Duty Licensure Name Professional School(s) Secondary Specialty Office Manager/ Business Office Staff Contact Hospital Privileges Past Work History Hospital Privileges & Other Affiliations General Information Training Certifications Payment and Remittance Gaps in Professional/ Work History Education, Training & Board Certification Home Address Professional IDs DEA CDS State License Other IDs Medicare Medicaid NPI USMLE Workers Comp Practice Interests Primary Credentialing Contact Office Hours Open Practice Status Mid-Level Practitioners Languages Accessibilities Professional References DEA or State Controlled Substance Registration Medicare, Medicaid or Other Governmental Program Participation Other Sanctions or Investigations Professional Liability Insurance Information and Claims History Services Malpractice Claims History Partners/ Associates Criminal/ Civil History Covering Colleagues Ability to Perform Job
7 Council for Affordable Quality Healthcare
8 Members of CAQH Aetna America s Health Insurance Plans AultCare BlueCross BlueShield Association BlueCross BlueShield of Michigan BlueCross BlueShield of North Carolina BlueCross BlueShield of Tennessee CareFirst BlueCross BlueShield Cigna Health Net Horizon BlueCross BlueShield of New Jersey Kaiser Permanente UnitedHealth Group WellPoint
9 PECOS
10 NPPES
The Credentialing Process. Note! Contents are subject to change and are not a guarantee of payment.
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