Credentialing
Mandatory
Elective
Reinforcement
Summary of the week
Wednesday
MONDAY
THURSDAY
Friday
Tuesday
DAY 3
DAY 4
DAY 5
Week 1
week 2
Week 3
Week 4
Week 5
What is Credentialing?
Day 1:
Topic 1:
A great title
What is Credentialing ?
Write a cool subtitle
Topic 2:
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Key Systems & Terms
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Topic 3:
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Why is Credentialing Important?
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Common Systems & Terms
LINKING: - This is when a provider practices and is paid under a shared Entity. - Tax Identification number (Also known as the TAX ID number or TIN or EIN. PROVIDER LOADING: - Commercial insurance payer specific task - Performed internally within the payers system to connect a credentialed provider with the contract covering the provider
Reassignment or Benefits: Reassigning Medicare benefits allows an eligible individual or entity to submit claims on behalf of and receive payment for Medicare Part B services that the performing practitioner provides for the eligible billing individual or entity. Both the individual practitioner and the eligible or entity must be currently enrolled in Medicare program before the reassignment can take effect.
National Provider Data Bank (NPDB)
Linking and Loading: Linking is when a provider is credentialing but has a group contract. The Provider is linked to the group tax identification number. The providers are all paid under the group tin instead of individually to their own personal social security number. Loading occurs when the insurance payer will make the Provider active in their system. The Provider has completed credentialing and is contracted with the payer either with a group or individually. The process of loading a physician can take several weeks to complete.
The Provider Enrollment Chain and Ownership System or PECOS. Is the online Medicare Enrollment management system which allows you to enroll as a Medicare provider or a supplier, revalidate, renew your enrollment, withdraw from the Medicare program, or review and update your information.
Council for Addordable Quality Healthcare: A centralized online platform for healthcare providers to submit and maintain credentialing in A centralized online platform for healthcare providers to submit and maintain credentialing information for insurance networks and payers. formation for insurance networks and payers.
Scope of Service: This can be defined by a series of documentation and educational requirements or based on licensure and provider type.
An application will ask what services the provider wants to perform in an office setting versus in a hospital. For newly graduated providers, the payer may want residency transcript showing past competency on certain services that were mastered while in school. This varies by the Provider type and education level. - The services allowed to be performed by the provider per their education, Provider Type, Licensure Type, Specialty Type, and state/federal law
Delegated Credentialing: is used by facilities in academic hospital settings. This is a way for bypassing the lengthy timeline of regular credentialing. The payers can grant an addendum to the contract allowing the facility to maintain their own credentialing With delegated credentialing, the facility is responsible for completing the primary source verification process typically performed by the insurance company.
It is the responsibility of the delegated entity to ensure that all the providers meet the standards as set forth by the insurance companies. - This is specifically for hospital systems or academic hospital settings - This is the ability for an organization to be able to provide attest to primary source verification - By accepting this responsability the organization is legally liable for trhuthfully and honestly maintining and complying to all credentialing requirements
PTAN: Provider Transaction Access Number
To help with the process, it is best to understand some of the Terminology used daily. Take some time to browse through the credentialing flashcards for terms you may not know.
Grand fathering: is becoming extremely rare in these times. Before board certification was a requirement for new providers, many a physician was a grandfathered from having to take the board certification exam
PSV: Primary Source Verification is usually performed by the insurance payer. The payer verifies all of the information on the submitted application and analyzes it for mismatched information or missing information. They determine if the information is accurate and complete. Each payer has their own process. In the case of Delegated Credentialing the facility will be the ones performing the primary source verification. - Past and current medical licensure - Malpractice History - Residency completion - Fellowship completion (if required) - Board exam completion and successful passing - Undergraduate education - Graducate education - Medical education
Retroactive Billing: is primarily used with Medicare and Medicaid, It is when the provider start date is before Credentialing is complete and all claims are held until final approval for your provider is obtained. Upon approval, you then submit the held claims to the insurance for payment - For Commercial carries, this is only achieved with prior approval by the insurance company. Get this approval in writing and have a clear date that is agreed upon by both parties
A PTAN is a Medicare only number issued to providers by Maximus upon enrollment to Medicare. When a Mac approves enrollment and issues an approval letter. The letter will contain the PTAN assigned to the provider. - This number is usually six digits and is assigned by type of service and location of the provider.
NPI: The National Provider Number, or NPI, is a health insurance Portability and Accountability Act HIPAA Administrative Simplification Standard. The NPI number is a unique identification number for all covered healthcare providers. This ten digit, intelligence free number will be assigned to the provider, and this number will follow the provider throughout their career in medicine. An NPI should be one of the first items a newly graduated provider should apply for. All credentialing applications require the NPI number. So without one, all credentialing will cease.
Assignment of an NPI is relatively quick, usually sent to the corresponding email within 24 hours of the request. There are two types of NPI numbers. Type 1 for the provider or individual, and Type 2 for a group or facility.
I&A (Identity & Access Management System)
This is the federal system that assigns NPPI Numbers to providers and groups. The NPPES is a system developed by the Centers for Medicare and Medicaid Services CMS to assign NPI numbers, search the NPI registry and make changes to the Provider profiles.
The identity and access management system I&A allows you to manage your providers Medicare enrollments and related online activities more easily and efficiently. I&A allows authorized officials and access managers to add and remove staff from their organization and control the functions accessible to those staff. I&A allows its users to quickly and securely manage connections between individual providers or organizational providers and their relationships with surrogates who work on their behalf.
- A system used to speed up Medicare enrollments and validations
Title
Title
Title
Title
Title
Title
- Get an NPI - Apply for a National Provider Identifier via NPPES
- Create an I&A Account - Register at the Identity & Access Management System ti get login credentials
- Log into PECOS - Go to PECOS and sign in using your I&A credentials
- Choose the correct CMS 855 Form - Select the form based on your provider tye (ex:CMS-855I for individuals)
- Complete the Application - Fill out your enrollment details and upload required documents.
- Sign & Submit Electronically - No need to mail anything - PECOS is fully digital
- Track Application Status - Receive email updates and follow up if corrections are needed
- Request CAQH ID - Via healthcare carrier or directly from CAQH ProView
- Create Account - Use CAQH to set up username and password
- Complete Application - Fill out standardized form with personal, professional, and licensure details
- Upload Documents - Includes Licenses, Malpractice Insurance, Certifications, etc.
- Attest - Confirm accuracy of all submitted info (Required every 120 days)
- Processing Time - Attestation is verified within 24-48 hours
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* When a Provider is granted credentialing or enrollment without being required to complete a formal examination or process; allowed to have a retro-effective date to the credentialing process *
The National Provider Data Bank or NPBD is the self-query national database where all detriments to a provider's practice history are reported.
- The ability for CMS to pay the linked TIN in place of paying the Provider directly- This identification of where to send payment is performed during enrollment
- Assign NPI Numbers - If you are credentialing a provider who already has an NPI, you will need to update the Provider's Profile in the NPPES system
Subtitle
Subtitle
Subtitle
Subtitle
Subtitle
- Medical malpractice payments
- Adverse licensure
- Clinical privilege actions
- Medicare and Medicaid Exclusions
A great title
We better understand visual content. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what matters. We associate visual content with emotions.
Link
A cool title
We understand visual content better. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what counts. We associate visual content with emotions.
+ info
A great title
We better understand visual content. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what matters. We associate visual content with emotions.
Link
Credentialing is a thorough evaluation conducted by insurance carriers to verify the qualifications, background, and legitimacy of healthcare providers. This process ensures that providers meet established standards for delivering care and are eligible to participate in insurance networks. Education Verification – Confirmation of medical schooling and training credentials Criminal Background Check – Review of any past legal infractions or criminal history Malpractice History – Examination of previous malpractice claims or disciplinary actions Identity Confirmation – Validation of personal and professional identityScope of Practice – Assessment of services the provider is authorized to perform Licensure Verification – Confirmation of active and valid professional licenses Professional Experience – Review of clinical experience and employment history Purpose: Credentialing protects patients, ensures compliance with regulatory standards, and maintains the integrity of healthcare networks.
What is Credentialing
it is an extensive vetting process conducted by the insurance carriers to make sure that the provider is who they say they are
Personal Identity
Education
Criminal Record
Expreience
Malpractice Claims
Scope of Practice
Licensure
+ info
A cool title
We understand visual content better. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what counts. We associate visual content with emotions.
+ info
A great title
We better grasp visual content. Visual content is associated with cognitive and psychological mechanisms. Things come in through our eyes, the first image is the one that matters. We associate visual content with emotions.
+ info
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Transcript
Credentialing
Mandatory
Elective
Reinforcement
Summary of the week
Wednesday
MONDAY
THURSDAY
Friday
Tuesday
DAY 3
DAY 4
DAY 5
Week 1
week 2
Week 3
Week 4
Week 5
What is Credentialing?
Day 1:
Topic 1:
A great title
What is Credentialing ?
Write a cool subtitle
Topic 2:
A great title
Write a cool subtitle
Key Systems & Terms
A great title
Topic 3:
Write a cool subtitle
Why is Credentialing Important?
A great title
Write a cool subtitle
Common Systems & Terms
LINKING: - This is when a provider practices and is paid under a shared Entity. - Tax Identification number (Also known as the TAX ID number or TIN or EIN. PROVIDER LOADING: - Commercial insurance payer specific task - Performed internally within the payers system to connect a credentialed provider with the contract covering the provider
Reassignment or Benefits: Reassigning Medicare benefits allows an eligible individual or entity to submit claims on behalf of and receive payment for Medicare Part B services that the performing practitioner provides for the eligible billing individual or entity. Both the individual practitioner and the eligible or entity must be currently enrolled in Medicare program before the reassignment can take effect.
National Provider Data Bank (NPDB)
Linking and Loading: Linking is when a provider is credentialing but has a group contract. The Provider is linked to the group tax identification number. The providers are all paid under the group tin instead of individually to their own personal social security number. Loading occurs when the insurance payer will make the Provider active in their system. The Provider has completed credentialing and is contracted with the payer either with a group or individually. The process of loading a physician can take several weeks to complete.
The Provider Enrollment Chain and Ownership System or PECOS. Is the online Medicare Enrollment management system which allows you to enroll as a Medicare provider or a supplier, revalidate, renew your enrollment, withdraw from the Medicare program, or review and update your information.
Council for Addordable Quality Healthcare: A centralized online platform for healthcare providers to submit and maintain credentialing in A centralized online platform for healthcare providers to submit and maintain credentialing information for insurance networks and payers. formation for insurance networks and payers.
Scope of Service: This can be defined by a series of documentation and educational requirements or based on licensure and provider type. An application will ask what services the provider wants to perform in an office setting versus in a hospital. For newly graduated providers, the payer may want residency transcript showing past competency on certain services that were mastered while in school. This varies by the Provider type and education level. - The services allowed to be performed by the provider per their education, Provider Type, Licensure Type, Specialty Type, and state/federal law
Delegated Credentialing: is used by facilities in academic hospital settings. This is a way for bypassing the lengthy timeline of regular credentialing. The payers can grant an addendum to the contract allowing the facility to maintain their own credentialing With delegated credentialing, the facility is responsible for completing the primary source verification process typically performed by the insurance company. It is the responsibility of the delegated entity to ensure that all the providers meet the standards as set forth by the insurance companies. - This is specifically for hospital systems or academic hospital settings - This is the ability for an organization to be able to provide attest to primary source verification - By accepting this responsability the organization is legally liable for trhuthfully and honestly maintining and complying to all credentialing requirements
PTAN: Provider Transaction Access Number
To help with the process, it is best to understand some of the Terminology used daily. Take some time to browse through the credentialing flashcards for terms you may not know.
Grand fathering: is becoming extremely rare in these times. Before board certification was a requirement for new providers, many a physician was a grandfathered from having to take the board certification exam
PSV: Primary Source Verification is usually performed by the insurance payer. The payer verifies all of the information on the submitted application and analyzes it for mismatched information or missing information. They determine if the information is accurate and complete. Each payer has their own process. In the case of Delegated Credentialing the facility will be the ones performing the primary source verification. - Past and current medical licensure - Malpractice History - Residency completion - Fellowship completion (if required) - Board exam completion and successful passing - Undergraduate education - Graducate education - Medical education
Retroactive Billing: is primarily used with Medicare and Medicaid, It is when the provider start date is before Credentialing is complete and all claims are held until final approval for your provider is obtained. Upon approval, you then submit the held claims to the insurance for payment - For Commercial carries, this is only achieved with prior approval by the insurance company. Get this approval in writing and have a clear date that is agreed upon by both parties
A PTAN is a Medicare only number issued to providers by Maximus upon enrollment to Medicare. When a Mac approves enrollment and issues an approval letter. The letter will contain the PTAN assigned to the provider. - This number is usually six digits and is assigned by type of service and location of the provider.
NPI: The National Provider Number, or NPI, is a health insurance Portability and Accountability Act HIPAA Administrative Simplification Standard. The NPI number is a unique identification number for all covered healthcare providers. This ten digit, intelligence free number will be assigned to the provider, and this number will follow the provider throughout their career in medicine. An NPI should be one of the first items a newly graduated provider should apply for. All credentialing applications require the NPI number. So without one, all credentialing will cease. Assignment of an NPI is relatively quick, usually sent to the corresponding email within 24 hours of the request. There are two types of NPI numbers. Type 1 for the provider or individual, and Type 2 for a group or facility.
I&A (Identity & Access Management System)
This is the federal system that assigns NPPI Numbers to providers and groups. The NPPES is a system developed by the Centers for Medicare and Medicaid Services CMS to assign NPI numbers, search the NPI registry and make changes to the Provider profiles.
The identity and access management system I&A allows you to manage your providers Medicare enrollments and related online activities more easily and efficiently. I&A allows authorized officials and access managers to add and remove staff from their organization and control the functions accessible to those staff. I&A allows its users to quickly and securely manage connections between individual providers or organizational providers and their relationships with surrogates who work on their behalf. - A system used to speed up Medicare enrollments and validations
Title
Title
Title
Title
Title
Title
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
Use this side to give more information about a topic.
* When a Provider is granted credentialing or enrollment without being required to complete a formal examination or process; allowed to have a retro-effective date to the credentialing process *
The National Provider Data Bank or NPBD is the self-query national database where all detriments to a provider's practice history are reported.
- The ability for CMS to pay the linked TIN in place of paying the Provider directly- This identification of where to send payment is performed during enrollment
- Assign NPI Numbers - If you are credentialing a provider who already has an NPI, you will need to update the Provider's Profile in the NPPES system
Subtitle
Subtitle
Subtitle
Subtitle
Subtitle
A great title
We better understand visual content. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what matters. We associate visual content with emotions.
Link
A cool title
We understand visual content better. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what counts. We associate visual content with emotions.
+ info
A great title
We better understand visual content. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what matters. We associate visual content with emotions.
Link
Credentialing is a thorough evaluation conducted by insurance carriers to verify the qualifications, background, and legitimacy of healthcare providers. This process ensures that providers meet established standards for delivering care and are eligible to participate in insurance networks. Education Verification – Confirmation of medical schooling and training credentials Criminal Background Check – Review of any past legal infractions or criminal history Malpractice History – Examination of previous malpractice claims or disciplinary actions Identity Confirmation – Validation of personal and professional identityScope of Practice – Assessment of services the provider is authorized to perform Licensure Verification – Confirmation of active and valid professional licenses Professional Experience – Review of clinical experience and employment history Purpose: Credentialing protects patients, ensures compliance with regulatory standards, and maintains the integrity of healthcare networks.
What is Credentialing
it is an extensive vetting process conducted by the insurance carriers to make sure that the provider is who they say they are
Personal Identity
Education
Criminal Record
Expreience
Malpractice Claims
Scope of Practice
Licensure
+ info
A cool title
We understand visual content better. Visual content is associated with cognitive and psychological mechanisms. Things enter through the eyes, the first image is what counts. We associate visual content with emotions.
+ info
A great title
We better grasp visual content. Visual content is associated with cognitive and psychological mechanisms. Things come in through our eyes, the first image is the one that matters. We associate visual content with emotions.
+ info