Credentialing Hot Topics

In the world of credentialing, you can always expect changes in the process or variations between insurance carriers. To avoid interruptions in your practice’s reimbursement and revenue cycle, you’ll want to become familiar with the most recent changes. Staying up to date can be challenging, so we’ve compiled a few tips to keep your enrollments on the right track.

Provider Enrollment Changes

• Important Documents
• Banking information is necessary for Medicare. The provider must have a bank account opened in the practice’s name. Enrollment cannot be processed without a voided check or bank letter signed by an authorized bank official. The voided check must be from the practice’s bank account. It must also be an actual check; it cannot be a temporary check that the bank will issue until your checks come in.
• It is also important to have malpractice insurance in place. You cannot practice without it, and many insurance companies will want a copy for enrollment. It’s also a requirement to keep your Council for Affordable Quality Healthcare (CAQH) profile updated. You’ll read more about the importance of CAQH below.
• Processing Times
  • Medicare: 30 days
  • Medicaid: 30 days
  • Commercial: 6-16 weeks
  • Blue Cross Complete: 6 months
  • Blue Cross Blue Shield of Michigan: 2 weeks
• Blue Cross Blue Shield of Michigan (BCBS) Group Changes
  As of January 1, 2018, group changes may be made only online. Paper applications will no longer be accepted. You must submit an Addendum G form to BCBS to gain access to a provider on the Provider Self-Service Tool located on WEBDENIS. New group enrollments and individual practitioner changes can still be made with paper applications.
• Changes to TRICARE
  As of January 1, 2018, TRICARE North combined with TRICARE South to become the new TRICARE East. Previously, TRICARE North was handled by Health Net Federal Services. Now, the Department of Defense awarded the contract to Humana Military. If a provider previously had a contract with TRICARE North, no action needs to be taken. The contract will be converted to Humana Military, and all dates of service before January 1, 2018, will still need to be billed to TRICARE North. All new provider enrollments must be done through Humana Military.

CAQH

Many insurance companies are now turning to CAQH for credential verification. One of the largest carriers is Blue Cross Blue Shield of Michigan. Blue Cross previously requested verification through PrimeHUB; an authorized individual would attest to the information on file for a given provider, or any number of providers. Now, Blue Cross sends requests for a provider’s CAQH profile to be updated and attested for. The attestation is crucial to provider enrollment – CAQH profiles must be attested for no earlier than 14 days before submitting enrollment applications. Blue Cross has advised us that they pull information from CAQH profiles every Monday.

PHOs

Provider Health Organizations are another helpful resource for provider enrollments. Providers can join one of these organizations and get help with credentialing. PHOs have a list of health insurance carriers they are partnered with and will handle all of the enrollments for those specific insurance carriers. This means that even if an insurance carrier has a closed network, being a member of a partnered PHO will allow enrollment to go forward. Joining a PHO will give you an advantage over providers who are not members of a PHO.

Providers should be warned that when they choose not to join a PHO, they risk being unable to get in a network with insurance carriers who have contracts with the PHO.

We hope these tips shed some light on changes in the credentialing process. Yeo & Yeo Medical Billing & Consulting is happy to offer additional information or assistance with your practice’s credentialing needs.