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The 2The 2ndnd Annual Client Annual Client ConferenceConference

October 16October 16thth & 17 & 17thth , 2006 , 2006

Welcome to the NetworkWelcome to the Network“Credentialing”“Credentialing”

Leona Roach, CPMSM, CPCSLeona Roach, CPMSM, CPCS

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DiscussionDiscussion

GlossaryGlossary

The New Provider ~ New to CCNV The New Provider ~ New to CCNV NetworkNetwork

Established Provider ~ Already In CCNV Established Provider ~ Already In CCNV NetworkNetwork

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GlossaryGlossary Completed applicationCompleted application ~ Questions answered; yes answers ~ Questions answered; yes answers

explained; application is signed; required documents listed on explained; application is signed; required documents listed on application are attached; letter of coverage; references are application are attached; letter of coverage; references are provided with contact information; provided with contact information;

Network contracted 3Network contracted 3rdrd party agreements party agreements ~ Contracts ~ Contracts negotiated at CCNV for our Health Centersnegotiated at CCNV for our Health Centers

Non-contracted 3Non-contracted 3rdrd party payer agreements party payer agreements ~ Contracts ~ Contracts negotiated by the Health Center for the Health Centernegotiated by the Health Center for the Health Center

Delegated credentialing contractsDelegated credentialing contracts ~ Network contracted 3 ~ Network contracted 3rdrd party payers who accept the CCNV Board decision for their party payers who accept the CCNV Board decision for their credentialing processcredentialing process

PSV PSV ~ Primary source verification~ Primary source verification

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Credentialing StaffCredentialing Staff

Cynthia Roberts, Senior Credentials AnalystCynthia Roberts, Senior Credentials Analyst Key Health Center Credentialing ContactKey Health Center Credentialing Contact

Tamika Rodriguez, Credentials AnalystTamika Rodriguez, Credentials Analyst

Angee Smith, CPCS, Credentials AnalystAngee Smith, CPCS, Credentials Analyst

Leona Roach, CPMSM, CPCS, DirectorLeona Roach, CPMSM, CPCS, Director

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The New ProviderThe New Provider

When does the credentialing process begin?When does the credentialing process begin? During employment negotiationsDuring employment negotiations Health Center pre-employment requirementsHealth Center pre-employment requirements Provide the CCNV application for completion Provide the CCNV application for completion

I have a signed employment contract, now I have a signed employment contract, now what?what? Forward the application and required documents to Forward the application and required documents to

CCNV Credentialing in timely mannerCCNV Credentialing in timely manner

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The Clock Begins ~ Working Days The Clock Begins ~ Working Days 1-21-2

When CCNV receives a completed application When CCNV receives a completed application Delays occur in processing if application is not Delays occur in processing if application is not

completecomplete Data entry and PSV is started within 24 hours Data entry and PSV is started within 24 hours

of receipt of completed applicationof receipt of completed application CAQH, Medicare and NPI applications are CAQH, Medicare and NPI applications are

updated or generated by Credentials Analystupdated or generated by Credentials Analyst

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Working Days 3-5Working Days 3-5

CCNV Network contracted 3CCNV Network contracted 3rdrd party payer party payer applications are filled outapplications are filled out

Non-contracted 3Non-contracted 3rdrd party payer applications are party payer applications are filled outfilled out Must be provided by Center ~ not an assumption Must be provided by Center ~ not an assumption

that can be madethat can be made 33rdrd party applications are then mailed to the party applications are then mailed to the

Health Center’s Credentialing ContactHealth Center’s Credentialing Contact

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Working Days 8 - 22Working Days 8 - 22

Center receives applications from CCNVCenter receives applications from CCNV Each application must be reviewed for Each application must be reviewed for

accuracy and completeness by provideraccuracy and completeness by provider Provider must answer questions and sign all Provider must answer questions and sign all

documents as requireddocuments as required Executive Directors may also be required to Executive Directors may also be required to

sign documents (Medicare)sign documents (Medicare)

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28 Calendar Days 28 Calendar Days

Center ? ~ My provider has been here 4 weeks, Center ? ~ My provider has been here 4 weeks, we haven’t received any provider number’s or we haven’t received any provider number’s or effective dates? effective dates?

CCNV ? ~ Have you received the 3CCNV ? ~ Have you received the 3rdrd party party applications from CCNV?applications from CCNV?

CCNV ? ~ Have the applications been CCNV ? ~ Have the applications been verified, signed and sent back to CCNV?verified, signed and sent back to CCNV?

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Working Days 18-25Working Days 18-25

33rdrd party payer applications are received by party payer applications are received by CCNV from Health CenterCCNV from Health Center Are they complete? What’s left to do?Are they complete? What’s left to do?

Each application must be prepared for mailingEach application must be prepared for mailing Copies of Licenses, DEA, FTCA/Malpractice, Copies of Licenses, DEA, FTCA/Malpractice,

Board Certifications, completed applications and Board Certifications, completed applications and other documents required by insurers.other documents required by insurers.

Applications are mailed to Network contracted Applications are mailed to Network contracted and non-contracted 3and non-contracted 3rdrd party payers party payers

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Working Days 29-34Working Days 29-34 PSV is completed and provider is accepted into the PSV is completed and provider is accepted into the

Network by the CCNV Board of DirectorsNetwork by the CCNV Board of Directors CCNV delegated 3CCNV delegated 3rdrd party payers are sent provider party payers are sent provider

demographics and verification of the CCNV demographics and verification of the CCNV credentialing processcredentialing process

Center: CCNV notified us that our provider was Center: CCNV notified us that our provider was accepted by the CCNV Board ~ When can we expect accepted by the CCNV Board ~ When can we expect to begin receiving provider #’s and effective dates?to begin receiving provider #’s and effective dates? Delegated payers ~ Approval date to 45 daysDelegated payers ~ Approval date to 45 days Contracted ~ Can be up to 90 daysContracted ~ Can be up to 90 days Out of Network ~ Can be up to 180 days or moreOut of Network ~ Can be up to 180 days or more

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End of Year Comparison

0

50

100

150

200

250

2003

2004

2005

2003 200 30 10.5 92 40

2004 231 34 81 63 35

2005 237 61 16 29 11

# of practitioner Termed Sign to receipt Initial to Complete Reappt to Complete

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Working Days 28-35Working Days 28-35

CCNV contacts all Network contracted and non-CCNV contacts all Network contracted and non-contracted 3contracted 3rdrd party payers to verify receipt of the party payers to verify receipt of the providers application for their credentialing processproviders application for their credentialing process Not in system ~ follow-up 5 daysNot in system ~ follow-up 5 days Yes ~ date is documented and follow-up schedule beginsYes ~ date is documented and follow-up schedule begins

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The Tracking ScheduleThe Tracking Schedule

Two weeks from verification of receiptTwo weeks from verification of receipt Do you need anything/have any questions?Do you need anything/have any questions?

Four weeks from verification of receiptFour weeks from verification of receipt Where are you in the credentialing process?Where are you in the credentialing process? Ready for your credentials meeting? When does Ready for your credentials meeting? When does

your committee meet?your committee meet?

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Meanwhile at CCNVMeanwhile at CCNV

Tracking continues until provider numbers and Tracking continues until provider numbers and effective dates are received or up to 90 dayseffective dates are received or up to 90 days

Upon notification of provider numbers, Upon notification of provider numbers, effective dates, approval notices ~ CCNV effective dates, approval notices ~ CCNV provides information to the Center’s provides information to the Center’s Credentialing ContactCredentialing Contact

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Meanwhile at Health CenterMeanwhile at Health Center

Health Center is completing the credentialing and Health Center is completing the credentialing and privileging approval process with their Board.privileging approval process with their Board.

Upon receipt of provider numbers and effective dates Upon receipt of provider numbers and effective dates from CCNV ~ Health Center is notifying ComCare from CCNV ~ Health Center is notifying ComCare for data load into Megawestfor data load into Megawest

If Health Center is receiving provider information If Health Center is receiving provider information from 3from 3rdrd party payers, this is being disseminated to party payers, this is being disseminated to CCNV Credentialing and ComCare immediatelyCCNV Credentialing and ComCare immediately

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In the Case of Missing NumbersIn the Case of Missing Numbers

After 90 days of tracking and not obtaining the After 90 days of tracking and not obtaining the necessary elements from the Network contracted 3necessary elements from the Network contracted 3rdrd party payers ~ CCNV Contracting is notified and party payers ~ CCNV Contracting is notified and begins investigating.begins investigating.

Center is notified that no response has been received Center is notified that no response has been received from non-contracted 3from non-contracted 3rdrd party payers party payers

After 90 days from the CCNV Board approval date, After 90 days from the CCNV Board approval date, the CCNV Credentialing process is now considered the CCNV Credentialing process is now considered completed. completed.

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The Established ProviderThe Established ProviderMoving Within NetworkMoving Within Network

An employment contract has already been An employment contract has already been negotiated.negotiated.

Does my provider need to fill out another Does my provider need to fill out another CCNV application?CCNV application?

Does my provider have to go through the Does my provider have to go through the processing of all those 3processing of all those 3rdrd party payer party payer applications again?! applications again?!

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Does My Provider Have to ….Does My Provider Have to ….

Fill out a CCNV application?Fill out a CCNV application? Yes and No ~ Center can request CCNV to send a pre-populated Yes and No ~ Center can request CCNV to send a pre-populated

application (basic demographic, education, training information) application (basic demographic, education, training information) Must be updated ~ (office information, questions answered, current Must be updated ~ (office information, questions answered, current

references, new attestation)references, new attestation) Why, the provider is already in the CCNV Network?Why, the provider is already in the CCNV Network?

Each Health Center must have a PSV file on each provider. Each Health Center must have a PSV file on each provider. Provider does not go through the CCNV Credentialing/BoardProvider does not go through the CCNV Credentialing/Board MUST go through Health Center’s Board approval process.MUST go through Health Center’s Board approval process.

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Does My Provider Have to ….Does My Provider Have to ….

Go through all the 3Go through all the 3rdrd party payer process party payer process again?again?

Not necessarily, but there are reasons that may Not necessarily, but there are reasons that may necessitate redundancynecessitate redundancy Provider was termed from CCNV Network longer Provider was termed from CCNV Network longer

than 30 days prior to new employmentthan 30 days prior to new employment Your Center may have other CCNV Network Your Center may have other CCNV Network

agreements not available at previous Centeragreements not available at previous Center Your Center may have non CCNV agreements Your Center may have non CCNV agreements

contracts that previous Center did not havecontracts that previous Center did not have

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Must Take PlaceMust Take Place

CAQH updateCAQH update Medicare updateMedicare update NPI updateNPI update Health Center Credentialing and Privileging Health Center Credentialing and Privileging

approval processapproval process

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To Add it UpTo Add it Up

The Process Takes Time and Two WayThe Process Takes Time and Two Way

COMMUNITCATIONCOMMUNITCATION

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DISCUSSION/QUESTIONSDISCUSSION/QUESTIONS

THANK YOUTHANK YOU