Universal Credentialing DataSource Overview for Participating Organizations

1. Universal Credentialing DataSourceOverview for Participating Organizations

2. An Introduction to CAQH The Council for Affordable Quality Healthcare (CAQH) is a not-for-profit alliance of health plans and networks that promotes collaborative initiatives to: • Make healthcare more affordable • Share knowledge to improve quality of care • Make administration easier for physicians and their patients

3. Member Organizations

4. Areas of Focus CAQH is working in two major areas with focus on designing and implementing achievable, concrete initiatives: • Administrative Simplification Making administration easier for physicians and consumers • Universal Credentialing DataSource • Formulary DataSource • Industry Standard Terminology • Quality of Care and Patient Safety Working with physicians and professional organizations to improve overall health care quality through national initiatives • Save Antibiotic StrengthSM • HeartBBEAT for LifeSM

5. Administrative Simplification: Universal Credentialing DataSource

6. What Is Credentialing Today and Why Is It Done • Systematic process employed by health plans, hospitals and other healthcare organizations to determine whether providers meet each organization’s respective quality standards for participation. • Performed by virtually all organizations for network quality, risk management and accreditation reasons. • Data collected via credentialing processes may be used within other business areas such as contracting, provider directories, member services and claims processing. • Return on investment is difficult to measure.

7. What Steps Are Involved • Health plans, hospitals and other organizations typically use paper applications to collect self-reported data from providers (education, training, experience, etc.). • Each organization then verifies certain provider-reported data against primary sources (Primary Source Verification or PSV) either internally or via a Credentials Verification Organization (CVO). • The organization presents the verified information to a review committee who makes an independent decision about whether the provider in question meets that organization’s standards for participation. 3 Credentialing Review and Decision 1 Credentialing Data Collection 2 Credentials Verification (PSV)

8. Data Collection Is the Most Inefficient Step 40% Obtaining a complete application 25% Primary Source Verification 35% File preparation, committee review, appeals, etc. 0% 20% 40% 60% 80% 100% • Manual process, usually involving combination of mail, fax, phone, and sometimes even office visits • Requires long lead time, and is primary reason why process begins 4-6 months before actual decision is made • Once application is complete, remaining steps proceed quickly • Automated process in most larger plans • Sometimes involves expensive licensing fees and strict sharing restrictions • Third-parties often involved • Moving toward automation; business rules enable plans to identify providers who require further research • Major component of file preparation is ensuring time-sensitive information meets freshness standards when presented to committee *Based on discussions with health plan representatives

9. Problems with Traditional Data Credentialing Processes The first step of the credentialing process has the following problems: • Redundancy: Providers are asked to complete multiple forms essentially requesting the same information. • Follow-up: Omitted and illegible responses requires significant resources and result in delays to timely processing. • Misalignment: Different credentialing cycles exacerbate the problem by requiring providers to complete the process at different points in time for different health plans and other organizations that perform credentialing. • Off-cycle updates: Diligent follow-up is required to maintain accurate data between credentialing events so that provider directories, referral, claims and other provider and member services are effective. • Turnaround: Providers are frustrated with time between application submission and when a decision is finally communicated back despite significantly improved processing by health plans

10. The Solution: Universal Credentialing DataSource One physician, One application, One source • Replace multiple plan-specific paper processes with a single, uniform data collection system • Key features include: • Completely free for providers to use • Providers can complete application online via interview-style questions or fax paper copy • Supporting documents are collected, imaged and attached to electronic record • Participating organizations can access data in electronic format at any time if authorized by provider • Data maintained in a “Perpetual State of Readiness” to avoid problems with differing recredentialing cycles – refreshed every 90 days • Updates can be made at any time and are immediately available to authorized organizations • 128-bit Secure Socket Layer Encryption (SSL) • Toll-free help desk to assist providers

11. Basic Overview Provider Advisory Panel User Group CAQH Via Internet or Fax Physicians CAQH Universal Credentialing DataSource Health Plans Chiropractors Podiatrists Hospitals Practice Administrator Module Online Application System (OAS) Data Access System (DAS) Mid-level Providers Other Healthcare Organizations Allied Health Providers - - - - - To be implemented in 2004

12. Benefits for Participating Organizations Participation in the Universal Credentialing DataSource initiative offers the following benefits to health plans, hospitals and other healthcare organizations: • Flexibility: Participating organizations are free to independently determine best options for primary source verification, including internal and third-party avenues. • Affordability: Not-for-profit status ensures that fees are kept low, and any revenue beyond expenses are redirected toward further system improvements. • Efficiency: Typically redundant data collection efforts are replaced with single, industry-wide system that allows participating organizations to focus on using data rather than chasing applications. • Automation: Availability of electronic data enables participating organizations to move away from manual, paper-based processes. • Provider Relations: Participation in initiative demonstrates leadership in industry and willingness to alleviate key factors in provider dissatisfaction.

13. Areas of Impact for Participating Organizations • Data errors and inconsistencies across departments • Inefficient claims processing due to erroneous billing information • Lack of electronic contact information for provider relations activities • Hassle factor for providers Tier 3: Other Inefficiencies • Provider directory maintenance • Other member service functions • Recruiting and network development paperwork • Provider data maintenance and other plan-wide IT operations • Application and supporting document storage and retrieval Tier 2: Non-Credentialing Costs • Tier 1: Direct and Indirect Costs • Pre-population and preparation of application • Mailing/handling of application (send-out and receipt) • Follow-up contacts to providers, “chasing” of application • Application completeness review • Data entry and/or scanning of applications and supporting documents • Archiving and offsite paper storage • IT support for application database maintenance • Provider relations field activity associated with follow-up • Management

14. Reduced Mailings: After 20 months of aggressively promoting the CAQH credentialing initiative, 72% of a plan’s providers in Colorado have successfully completed their applications – no more outreach required Result: 36% fewer providers to contact via mail each month during remaining 16 months of 3-year recredentialing cycle Turnaround: One plan has found that applications submitted via the CAQH system usually require little follow-up with provider offices Result: Quicker plan credentialing decisions on CAQH applications Paperless: While an automated solution is being developed, a plan’s data entry personnel currently toggle between CAQH-supplied electronic images and their respective data entry screens Result: Reductions in printer costs, paper procurement, filing needs and offsite archiving because applications can be viewed and stored electronically Automation: One plan downloads raw data directly from the CAQH system into its provider data system, which in turn feeds other systems. Result: Reductions in data entry resources, and improvement in data quality Early Results from Current Participants

15. Media Coverage Highlights to Date Healthplan Magazine

16. How It Works 1. Participating health plans and other healthcare organizations submit a roster of their respective providers to CAQH. Alternatively, health plans can create their roster online via the participating organization side of the system – called the Data Access System (DAS). Online tool to help participating organizations add providers to their roster

17. How It Works 2. CAQH mails Registration Kits to all unique providers appearing on at least one submitted roster. The Registration Kit contains a unique CAQH Provider ID, as well as instructions on how to access the provider side of the system – called the Online Application System (OAS). Welcome screen for Online Application System (OAS) where new users can register

18. How It Works 3. Once in the system, the provider creates a username and confidential password. With this username and confidential password, the provider can begin to complete the application online. If the provider prefers, a paper application can be requested from the toll-free help desk. Interview-style questions help providers navigate application one section at a time

19. How It Works 4. Before the completed application is available to any participating organization, the provider must authorize release of his or her data. All of the organizations who have included the provider on their respective rosters are listed here for the provider to review and authorize. Authorization screen ensures providers have complete control over which organizations have access to their information

20. How It Works 5. The provider must then generate a fax cover sheet and fax any required supporting documents to a toll-free fax number. These documents are imaged and attached electronically to the provider’s file. The last step for providers is to fax all necessary supporting documentation

21. How It Works 6. Once the application is complete, authorized participating organizations are sent data in their preferred format: (A) ASCII; (B) XML; or, (C) static PDF images of applications. Subsequent updates to data are also available in the same formats. A Complete applications can be retrieved by participating organziations in the format of their choice B C

22. Aetna Anthem Blue Cross and Blue Shield AultCare Blue Cross Blue Shield of Georgia* Blue Cross Blue Shield of Kansas City Blue Cross Blue Shield of Michigan Blue Cross Blue Shield of Missouri* Blue Cross Blue Shield of North Carolina Blue Cross of California* CareFirst Blue Cross Blue Shield CIGNA Healthcare Culpeper PHO Community Care Physicians Empire Blue Cross Blue Shield Excellus Health Plan The First Health Network Great-West Healthcare / One Health Plan Health Net, Inc. HealthLink* HealthPlan of Michigan Horizon Blue Cross Blue Shield of New Jersey Independent Health Kaiser Foundation Health Plan of the Mid-Atlantic States MAMSI Health Plans MultiPlan, Inc. Oxford Health Plans Preferred Care Rocky Mountain Health Plans Sentara Healthcare UNICARE* Virginia Premier * Part of WellPoint Health Networks Who Is Involved So Far? The list of participating organizations continues to grow, and includes non-member organizations (as of 2/12/04):

23. Progress to Date • Over 42,000 providers have already successfully completed the CAQH application via the paper or online process and the numbers are increasing daily • Launched in 43 states and District of Columbia (as of 2/12/04; remaining states to launch shortly) • Over 69,000 providers have already registered with system in all launched markets • Providers who have used the Universal Credentialing DataSource thus far have relationships with an average of 4 participating organizations – over 160,000 legacy credentialing applications have been eliminated • Once complete, providers will no longer need to submit additional credentialing paperwork as new organizations join initiative

24. Costs • The CAQH credentialing solution is completely free for providers to use. • Participation is offered to all organizations – membership in CAQH is not required. • Participating organizations are charged a standard fee per provider per year for unlimited access to data and any updates received, plus a small annual administrative fee for the organization overall – just enough to cover the operating costs • Organizations will only be charged for providers whose applications are complete and are authorized for release Automation and timely provider data will likely result in organizational savings that offset the costs to participate

25. How to Get Started • Contact CAQH for more information: Atul Pathiyal Project Director, Credentialing apathiyal@caqh.org 202-778-3285 • Schedule system demonstration • Review and execute contract • Prepare roster of providers and submit to CAQH • Begin downloading provider information from Universal Credentialing DataSource

26. www.CAQH.org