Understanding Payor Enrollment Carrie Bradford MHA RHIA CPMSM

Understanding Payor Enrollment Carrie Bradford, MHA, RHIA, CPMSM, CPCS Senior Director Professional Staff Services and Credentialing North. Shore University Health. System Evanston, IL

Payor Enrollment Traditionally a function of the business office or finance Completion of forms/processes to enroll providers for payment for services rendered Best practice: should always be for providers who are your employees or are contracted for. Watch out for stark!

Payor Enrollment Definitions Facility and Organization Dependent Government Plans Medicare/Medicaid Contracted Plans Third Party Payors: Aetna, Cigna, BCBS

Government Plans Medicare 101 Part A – Part B 855 -I & 855 -R List of accepted providers Paper submission vs. Electronic PECOS (Provider Enrollment Chain and Ownership System

Government Plans Medicare Administrative Contractors (MACS) Process Enrollment Process Claims Determined/Contracted by CMS Medicare “opt out” lists are on MAC pages for your state

Government Plans Medicare Enrollment Process Wait…lets not forget about location…location Medicare provider helpline on your MAC website Paper vs. PECOS Leverage your software Use the correct form, if not sure call the hotline TAT with MAC Claims retro back 6 months

Government Plans PECOS The NPPES (National Plan and Provider Enumeration System) NPI login is a providers PECOS Log in Provider must grant you authority to change record on their behalf. (meaninful use, pecos, nppes coming soon) Identity and Access System of CMS designates your level of access. This is granted by your organizations Authorized or Designated Official

Government Plans Medicaid Enrollment State based process Paper now evolving to electronic Other state programs can be intertwined in this enrollment TAT varies Leverage your software

Government Plans Revalidation Requirement of the Affordable Care Act Reduces Fraud/Waste Cleans up the MAC mess Once every 5 years…this is really not true in all cases

Contracted Plans Managed Care Contracting Who – IPA, PHO… What – providers/large groups Why – for reimbursement at a GOOD rate How – thru a contract Where do we fit in? ? NCQA…. and delegation

Contracted Plans Managed Care Credentialing CAQH…Council for Affordable Quality Healthcare Data repository “Proview” Plans must give provider a number Data entry along with certificates Initial and Recredential – Reattest every 120 days Duplicative for some

Contracted Plans Managed Care Credentialing Delegation Addendum to your managed care contract – READ IT Yearly audit…even for those who have NCQA CVO cert Checklist Gets your providers in quickly…$$$ Rosters Information Updates No secondary database requirements

Resources Websites: List of MACS https: //www. cms. gov/Medicare-Contracting/Medicare. Administrative-Contractors/MACJurisdictions. htmlwww. Medicare Managed Care https: //www. cms. gov/Regulations-and. Guidance/Manuals/downloads/mc 86 c 06. pdf CAQH http: //www. caqh. org/solutions/caqh-proview-providers-and-practicemanagers

Questions? Thank you! Email: cbradford@northshore. org