-Credentialing Plus+
Using Credentialing +
An MCO must credential every provider with which they will be doing business. The Credentialing + process includes primary source verification of licenses, degrees and insurance, all based on an application submitted by the provider. If after verifying a provider’s information the MCO chooses to do business with them, the provider can be activated through this module and they will become a provider within the system.
As credentialing is a recurring event, if any Provider, Site, Site Contact, Clinician, Contract, or Contract detail goes under credentialing MCS will restrict the ability to edit those records in Maintain Provider Info module.
You will then see the five tabs of the module:
1) Application
2) Provider
3) Sites
4) Clinician
5) Credentialing Services
PSV (Primary Source Verification)
In each part of the Credentialing + you will go back to the Primary Source Verification (PSV) tile (which is the same throughout the module, no matter which tab you are in). To begin the process of (PSV), first highlight the application you want to work on.
In the Credentialing + Module, the Link Type option is upgraded to a drop down menu. The Link Type will default to the PSV type according to the tab selected.
*The only exception is in the Sites Tab where the user will choose between Site and Site Contact.
APPLICATION TAB
The first tab you’ll see will be the Application tab.
The Applications Tile will show you all the applications that are currently under credentialing. To enter a new application, click the CREATE button.
This will allow you to enter the information for the application that the provider has sent to you.
There are many dates to be filled in—some of which are auto-filled for you based on other information you’ve already entered. (See below for details about the Applications Tile).
Below is a brief description of each field:
Application Packet #: The application ID number.
Provider Name: Name of the provider as it will be seen in Provider Maintenance (SEARCH and CREATE are available).
Application Date: Date you received the initial application.
Review Completed: Date you actually confirmed the application has been submitted in full.
Request For Info (RFI) #1 Sent: The date the application is sent.
RFI#1 Due: The date the info is requested by. *This will default to the RFI#1 Sent Date + 14 days. This can be changed by the MCO.
Final RFI Sent: The date that the final request was sent.
Discrepancy Noted: Check this if there are any discrepancies between the info provided by the applicant and info obtained from other sources.
Final RFI Due: The date that the final RFI is due. *This will default to the Final RFI Sent + 14 days. This can be changed by the MCO.
PSV Complete: When all Primary Source Verifications have been completed.
Application Status: This is a dropdown is used to specify the current owner of the application or if the application is pending.
Application Type: Choose from the available options in the drop down list.
Application Expiration Date: Date the application expires.
*This will default to 180 days from the Application Date. This can be changed by the MCO.
NPI #: NPI number of the Provider
Review Due: When you need to confirm that everything was included in the application packet. *This will default to 10 days after the Notification Sent Date. This can be changed by the MCO.
Supplemental Reviewer: User who completed the supplemental review.
Packet Complete: Check this if the application has been submitted in full. If it hasn’t been, leave unchecked and enter a Resubmission Due.
Packet Returned: Date you actually returned the incomplete packet and mailed the certified letter.
Packet Resubmitted: When it was actually sent in and you’re able to move forward with credentialing.
Notification Sent: When the letter was sent notifying the applicant of the discrepancy.
Additional Info Received: Date the clarifying information is actually received.
Referral Date: When the file has been referred to the Medical Director/Credentialing Committee for a determination.
Sign Off Details
Cred Specialist/Quality Auditor/Cred Supervisor/Medical Director: User ID and Date of the “signature”. **Must have all four signatures for Approval**
Signature Date: This field is updated by the QA level or higher.
Determination: Dropdown box giving options for Approved, Approved with Contingencies, and Denied. (Exception is for the Cred Specialist- the dropdown options at this level are: Previously Credentialed, Provider No Longer Employed, Voluntary Withdrawal, or Application Rejected/Does not meet minimum eligibility criteria)
Determination Date: When the determination was actually made.
Outcome Letter: When the applicant has been informed of the outcome. This field is manually updated by the user.
Expiration Date: This is the date the application expires. *This will default to 3 years based off of Medical Director Signature Date.
Comments: You can add additional notes and/or info.
When you’ve entered the necessary information, click SAVE. The application will now appear on the Applications tile.
Now notice that a checklist has been created in the Checklist Tile. This will show everything that needs to be done for the provider to be credentialed.
As items on the checklist are completed, you can mark them off by highlighting the item and clicking the “3” view in the upper righthand corner of the tile.
This will cause an Update and a View buttons to appear.
Click on the Update button.
Fill in the necessary information and click Save.
If you enter “Accepted” as the Status, the checklist item will show as Active on the Checklist tile.
PROVIDER TAB
Once you’ve found the application you want to work on or have completed a new application, click on the Provider tab.
In the Providers Tile, you are able to update the provider associated with the application you just selected. To do this, click the “3” View button and then UPDATE.
Fill in the necessary information and click Update.
Next, go to the PSV tile.
Fill in the necessary information. If the PSV is verified, make sure to check the Verified checkbox and choose the staff person who performed the verification in the dropdown.
The Reason field is where you’re able to note why something wasn’t verified. The Credential ID field is where you can enter information about the actual credential (e.g. the insurance number if you’re checking malpractice insurance).
When you click Save, the PSV will display in the tile.
SITES TAB
The Sites tab has three tiles. Sites, Site Contacts, and PSV’s.
Clicking Create on the Sites Tile will take you the details screen. Enter the information, noting the required fields and click UPDATE.
Expand the PSV tab and enter any PSV’s for the sites you’ve entered.
*Note that the PSV screen is the same in all tabs. As stated earlier the Sites Tab is the one exception. The Link Type does have a choice in the dropdown.
CLINICIAN TAB
The Clinician tab has three tiles. Clinicians, Provider Associated and PSV’s. In the Clinician Tab the user can update Clinician info and again get to the PSV’s tile.
In the Clinicians Tile, the user can search for an existing clinician to be loaded into the record. If you have the clinician info already, you also have the ability to manually enter the data.
The Provider Associated Tile is a view only detail. Below is shown in the “3” View.
*Once you have completed the necessary fields (noting the required fields in the Clinicians Tile with the red asterisks), click SAVE and continue to the PSV’s once again.
CREDENTIALING SERVICES TAB
The Credentialing Services Tab has three tiles. Contracts, Contract Details, and PSV’s. In the Contract Tab the user can update Contract Info, Contract Details and again get to the PSV’s tile.
Clicking CREATE on the Contracts Tile will take you the details screen. Enter the information, noting the required fields and click SAVE.
In the Contract Details tile, the main Contract tile will display along with any active contract records (there are no current active contracts in the example below) for the Provider listed. Users will have the ability to create new contracts or update existing contracts.
*Note the Contract Tile is showing MEDICAID. Only Medicaid Codes can be added in this example.
To add a code, click ADD. Type in a code and Search for the code in question. Once you have your results, check the boxes under the “Add to CD” column that you would like associated.
Once you have decided which details to add, click SAVE.
Again, enter any corresponding PSV’s.
*Note that the PSV screen is the same in all tabs.
SIGN OFF
Once all checklist items have been accepted and all PSV’s have been verified, go back to the Application tab. Click the “3” view and find the application you’ve been working on.
Click the Update button to go back into the application.
Now that all four required signatures have been updated onto the application, a determination can be made.
Go to the Determination dropdown and select Approved, Approved with Contingencies, or Denied. The final decision will require four (4) sign offs. Once those four signatures have been updated, click Update and you will be taken back out to the base tile.
* After choosing any Determination (Approved, Approved with Contingencies, or Denied), the user will not be able to update any fields. The exceptions to this are the: Sign off section and Determination field.
* If the user changes the Application Status then there will be a warning message indicating that the Sign off section will be cleared down to the level of the Application Status.
*If a Determination is chosen, the application will become locked from editing. The user can select a blank determination from the dropdown menu to unlock the application.
As a final detail:
IF YOU HAVE ANY OUTSTANDING CHECKLIST ITEMS OR PSV’s, the system won’t allow you to say the application is Approved. It will tell you what needs to be completed in order to do this.
After all details are updated, saved and verified, the ACTIVATE button will be enabled.
Click this and the provider will be active in your system and the application will be locked. This is your final step.
You will see the Determination and Status columns showing APPROVED and COMPLETED (respectively).