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Provider/Payer Enrollment Tips and
TricksThea Hensley
Provider Enrollment Coordinator
Cody Regional Health
307-578-2498
Vocabulary
Provider/Payer Enrollment-Refers to the gathering and submitting of information to payers in order to join their networks.
Network-The group of facilities and providers an insurance companies has approved for enrollment. Networks allow patients to utilize maximum benefits for services rendered. Smaller out of pocket costs for the patient.
Credentialing- 1. Used by Medical Staff Services to describe what they do when onboarding a provider.
Making sure the provider is qualified to practice.
2. Used by insurance companies in the onboarding of providers to their networks.
Provider/Payer Enrollment is NOT credentialing. The insurance companies may credential for their purposes but the Provider/Payer Enrollment process is not credentialing.
What is the purpose and why is it important?
To be able to provide services for patients at the best rate for the patient.
In some cases including Medicare, to get the facility paid.
Some insurance contracts state we can’t bill a patient if our provider is out of network for the patients plan.
Where does Provider/Payer Enrollment belong?
Medical Staff Services Allows for information sharing without breaking the rules.
Allows providers to find everyone they need all in one place in case of questions.
Patient Financial Services Allows for accurate billing processes, especially for obscure insurance companies.
Ability to communicate with the CFO regarding insurance contracts.
Allows communication and the ability to train with registration staff.
Where to start.
Make a list of your most billed insurance companies. See slide 12 for my list.
Contact all of the insurance companies’ Provider Enrollment/Credentialing departments and get a current roster.
Use those rosters to compare to your current provider list and build a spreadsheet.
Fill in “holes” by using the insurance companies websites to check the providers participation.
Physician Name Medicare Medicaid BCBS Cigna FC Midwest Dr.A 6/1/2015 12/15/2015 x 7/1/2012 xDr.B 4/1/2016 9/1/2015 9/4/2015 9/1/2016Dr.C 11/1/2013 2/11/2015 11/1/2013 3/21/2014 xDr. D 12/4/2017 12/19/2017 2/6/2018 xDr. E 4/1/2015 4/1/2015 4/1/2015 4/24/2015 xDr. F 2/5/2015 10/8/2013 8/12/2013 x
The Top Two
Wyoming Medicaid and Medicare
Wyoming Medicaidhttps://wymedicaid.portal.conduent.com/
If a provider is listed on this spreadsheet they are active with WY Medicaid.
*Every provider listed on a WY Medicaid claim has to be an enrolled provider or the claim will not be paid. This includes providers referring for labs and radiology.
Linking a WY Medicaid Provider to an Enrolled Group.If it is an initial enrollment, add the linking information in the Additional Information section on the application.
Example wording: Please link Dr. A, NPI 123456789 to The Group XYZ, NPI 123456789 effective 05/01/2018.
If it is for linking an existing WY Medicaid provider, fax a letter on letterhead, with the linking information to Conduent 307-772-8405. You can also email them the information at [email protected] email can also be used to send updated license information.Updates take about 2 business days to complete.
MEDICARE
MedicarePaper vs. PECOS
Paper Pros Paper Cons
Straight forward if you know the fields.
Confusing 30pg application with little instruction.
Hand to the provider for signature.
The amount of paper.
Scanned or copied record of submission.
PECOS Pros PECOS Cons
Electronic Provider has to know login info and give “surrogacy”
Application guided by questions answered.
Provider has to electronically sign in timely manner.
Medicare Forms 855I and 855R CMS-855I
All providers enrolling with Medicare in their area for the first time. Noridian is the MAC for WY. If the provider is currently enrolled in AK, AZ, ID, MT, ND, OR, SD, UT, WA or WY, this form is not necessary.
All providers need completed sections 1,2,3,4b,13 and 15
PA-C’s cannot reassign benefits so they do not complete section 4
Nurse Practitioners must answer section 2 section K regarding SNF services.
A copy of the Nurse Practitioners diploma must accompany the application.
CMS-855R
Must accompany the CMS-855I for all providers except PA-C’s.
If the provider is already enrolled with the MAC this is the only form needed.
Must be signed by the provider and a Delegated or Authorized Official from the group.
Commercial Payers
Must Have Information, for a Complete Provider/Payer Enrollment.
Name, DOB, SSN, NPI
Education, Internships, Residencies, Fellowships including Month and Year of start and completion.
Licenses: State License, DEA (Must reflect WY address), CDS
Board Certifications
CV
Medical Malpractice Insurance information
Three professional references. Include Name, Specialty and Phone Number. CAN’T use Peer References.
Information on any Medical Malpractice claims in the last 10 years. Must get from provider, can’t use information used for credentialing.
CAQH for Commercial Payer Enrollment
CAQH (Council for Affordable Quality Healthcare, Inc.) is essentially a credentialing database.
Cigna and United Healthcare require providers to have an up to date CAQH profile before they will accept for enrollment.
Start to Finish a profile takes 1-5 hours to finish depending on providers history.
Needs re-attestation every 120 days
Even after a profile is built you have to contact the insurance companies to initiate their credentialing process.
New Provider Process Make sure I have everything I need (see slide 14)
I do start applications without references and malpractice claim information. I just can’t submit until I get it.
Check Insurance websites for provider participation to determine if I need a whole application or just add them to the group. (insurance specific)
Check CAQH to see if they have a profile. NO? -Start to build one
Yes!- Find out if the provider has their login info or if it is with their previous group.
Have the provider look over and sign the completed applications.
Send applications and supporting documentation, via certified mail, fax or email to the insurance companies. (insurance specific)
WAIT- Some companies have a quick turn around, I have seen some take over 200 days. Keep an eye on your email and snail mail for approval letters and dates.
Watch your mail for re-enrollment/re-credentialing requests every 3-5 years depending on the company.
Training and Information Resources
Decision Health- National Provider Enrollment Conference
CMS.GOV
UHC News Bulletin
Q&A
