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The 2 nd Annual Client Conference October 16 th & 17 th , 2006

The 2 nd Annual Client Conference October 16 th & 17 th , 2006. Welcome to the Network “Credentialing” Leona Roach, CPMSM, CPCS. Discussion. Glossary The New Provider ~ New to CCNV Network Established Provider ~ Already In CCNV Network. Glossary.

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The 2 nd Annual Client Conference October 16 th & 17 th , 2006

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  1. The 2nd Annual Client ConferenceOctober 16th & 17th , 2006 Welcome to the Network“Credentialing” Leona Roach, CPMSM, CPCS

  2. Discussion • Glossary • The New Provider ~ New to CCNV Network • Established Provider ~ Already In CCNV Network

  3. Glossary • Completed application ~ Questions answered; yes answers explained; application is signed; required documents listed on application are attached; letter of coverage; references are provided with contact information; • Network contracted 3rd party agreements ~ Contracts negotiated at CCNV for our Health Centers • Non-contracted 3rd party payer agreements ~ Contracts negotiated by the Health Center for the Health Center • Delegated credentialing contracts ~ Network contracted 3rd party payers who accept the CCNV Board decision for their credentialing process • PSV ~ Primary source verification

  4. Credentialing Staff • Cynthia Roberts, Senior Credentials Analyst • Key Health Center Credentialing Contact • Tamika Rodriguez, Credentials Analyst • Angee Smith, CPCS, Credentials Analyst • Leona Roach, CPMSM, CPCS, Director

  5. The New Provider • When does the credentialing process begin? • During employment negotiations • Health Center pre-employment requirements • Provide the CCNV application for completion • I have a signed employment contract, now what? • Forward the application and required documents to CCNV Credentialing in timely manner

  6. The Clock Begins ~ Working Days 1-2 • When CCNV receives a completed application • Delays occur in processing if application is not complete • Data entry and PSV is started within 24 hours of receipt of completed application • CAQH, Medicare and NPI applications are updated or generated by Credentials Analyst

  7. Working Days 3-5 • CCNV Network contracted 3rd party payer applications are filled out • Non-contracted 3rd party payer applications are filled out • Must be provided by Center ~ not an assumption that can be made • 3rd party applications are then mailed to the Health Center’s Credentialing Contact

  8. Working Days 8 - 22 • Center receives applications from CCNV • Each application must be reviewed for accuracy and completeness by provider • Provider must answer questions and sign all documents as required • Executive Directors may also be required to sign documents (Medicare)

  9. 28 Calendar Days • Center ? ~ My provider has been here 4 weeks, we haven’t received any provider number’s or effective dates? • CCNV ? ~ Have you received the 3rd party applications from CCNV? • CCNV ? ~ Have the applications been verified, signed and sent back to CCNV?

  10. Working Days 18-25 • 3rd party payer applications are received by CCNV from Health Center • Are they complete? What’s left to do? • Each application must be prepared for mailing • Copies of Licenses, DEA, FTCA/Malpractice, Board Certifications, completed applications and other documents required by insurers. • Applications are mailed to Network contracted and non-contracted 3rd party payers

  11. Working Days 29-34 • PSV is completed and provider is accepted into the Network by the CCNV Board of Directors • CCNV delegated 3rd party payers are sent provider demographics and verification of the CCNV credentialing process • Center: CCNV notified us that our provider was accepted by the CCNV Board ~ When can we expect to begin receiving provider #’s and effective dates? • Delegated payers ~ Approval date to 45 days • Contracted ~ Can be up to 90 days • Out of Network ~ Can be up to 180 days or more

  12. Working Days 28-35 • CCNV contacts all Network contracted and non-contracted 3rd party payers to verify receipt of the providers application for their credentialing process • Not in system ~ follow-up 5 days • Yes ~ date is documented and follow-up schedule begins

  13. The Tracking Schedule • Two weeks from verification of receipt • Do you need anything/have any questions? • Four weeks from verification of receipt • Where are you in the credentialing process? • Ready for your credentials meeting? When does your committee meet?

  14. Meanwhile at CCNV • Tracking continues until provider numbers and effective dates are received or up to 90 days • Upon notification of provider numbers, effective dates, approval notices ~ CCNV provides information to the Center’s Credentialing Contact

  15. Meanwhile at Health Center • Health Center is completing the credentialing and privileging approval process with their Board. • Upon receipt of provider numbers and effective dates from CCNV ~ Health Center is notifying ComCare for data load into Megawest • If Health Center is receiving provider information from 3rd party payers, this is being disseminated to CCNV Credentialing and ComCare immediately

  16. In the Case of Missing Numbers • After 90 days of tracking and not obtaining the necessary elements from the Network contracted 3rd party payers ~ CCNV Contracting is notified and begins investigating. • Center is notified that no response has been received from non-contracted 3rd party payers • After 90 days from the CCNV Board approval date, the CCNV Credentialing process is now considered completed.

  17. The Established ProviderMoving Within Network • An employment contract has already been negotiated. • Does my provider need to fill out another CCNV application? • Does my provider have to go through the processing of all those 3rd party payer applications again?!

  18. Does My Provider Have to …. • Fill out a CCNV application? • Yes and No ~ Center can request CCNV to send a pre-populated application (basic demographic, education, training information) • Must be updated ~ (office information, questions answered, current references, new attestation) • Why, the provider is already in the CCNV Network? • Each Health Center must have a PSV file on each provider. • Provider does not go through the CCNV Credentialing/Board • MUST go through Health Center’s Board approval process.

  19. Does My Provider Have to …. • Go through all the 3rd party payer process again? • Not necessarily, but there are reasons that may necessitate redundancy • Provider was termed from CCNV Network longer than 30 days prior to new employment • Your Center may have other CCNV Network agreements not available at previous Center • Your Center may have non CCNV agreements contracts that previous Center did not have

  20. Must Take Place • CAQH update • Medicare update • NPI update • Health Center Credentialing and Privileging approval process

  21. To Add it Up • The Process Takes Time and Two Way COMMUNITCATION

  22. DISCUSSION/QUESTIONS THANK YOU

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