Credentialing & Payer Enrollment – A Team Approach Gwen Gilchrist, Joanna Hazell, Kate Powers January 24, 2017

Agenda Department Structure Electronic Notification Process Process “Start to Finish” Credentialing Application Enrollment Process Sharing of Information via communication and systems

Provider Services Department Responsible for Credentialing, Health Plan Enrollment, and Provider Data Management for Brigham and Women’s Hospital (BWH), Brigham and Women’s Faulkner Hospital (BWFH), and Brigham and Women’s Physicians Organization (BWPO). Total BWH / BWFH Credentialed Providers: approx 5500 Total BWPO Enrolled Providers: approx 2250

How it all Begins Electronic Notification Process Description of Clinical Responsibility (DCR) Form is submitted electronically by the appointing (clinical) department Credentialing Administrator and Enrollment Specialist receive email notification simultaneously when DCR is submitted Notification allows credentialing and enrollment process to run concurrently, as appropriate

DCR Form Description of Clinical Responsibility (DCR) used to notify Provider Services of the following: New Applicant Modifications to Existing Appointment Expansion of Current Privileges Change of Status Promotion Change in Health Plan Enrollment Status Separate Option to Submit Terminations All steps in electronic process are “time and date stamped”

Brigham and Women's Hospital Description of Clinical Responsibility & BWPO Eligiblity Criteria James P. ([DPSOH M.D. Step Date/Time User DCR Created: DCR Submitted: DCR Processed: 1/5/2017 9:23:18 AM 1/5/2017 9:27:38 AM 1/5/2017 9:29:16 AM Dept Contact Name Dept Contact Name Credentialing Admin Name DCR Type: New Appointment DCR ID: 10681 MPRN: 25838 Requested Effective Date: 7/31/2017 GENESYS: 7235203 Personal Information Gender DOB SSN Home Address Appointment Information: Department Division Section BWH Title Staff Category Specialty Clinical Privileges Admit Privileges Supervisor M 2/22/19XX XXX-XX-XXX 5474 South Boston MA Appointment 1 Anesthesiology Anesthesiologist Active Yes No Supervising M.D. Home Phone Mobile Phone Partners Email Personal Email AHP/APP Researcher Admin Contact 555-5555 MD@gmail Contact Name ID Numbers/Malpractice BWPO Practice Sites Limited License Req. NPI J-1 Clinical Visa Req. BWH Malpractice Req. BWPO Billing BWPO Class BWPO Rate Type CFTE Percent Hosp Payroll Statewide Rates 10 Yes No No Other Malpractice Req. <10% Reason Billing Location: Dr. Example will be a Dual/ERAP cardiothoracic fellow effective 07/31/2017. Category: Specialist Hospitalist No Intensivist No Non-MD Billing No Comments Signatures Dept Chair or Admin Official 1 Official 2 Official 3 Electronically Signed By Date Signed 1/5/2017 BWH Description of Clinical Responsibility & BWPO Eligiblity Criteria, Report Date: 1/17/2017 Page 1 of 1

Credentialing Process Link to on-line application sent to provider via email Application (IMA format) completed via web portal Credentialing Administrator (CA) receives electronic notification when application is submitted CA begins processing application and conducting primary source verifications All steps in the application process are “time and date stamped” CA works closely with appointing department as file is completed CA meets, as necessary, with Enrollment Specialist to share documents for enrollment process (“POD” meetings)

Provider Enrollment Process Enrollment Specialists work closely with Credentialing to review and track the following: Application (IMA) data “Exception Review” information Potential delays in approval process Committee approval notification Obtain copies of licensure, as required, for enrollment purposes Enrollment specialists generate tracking reports to be shared with appointing departments Access to enrollment effective dates granted to contacts in billing and the appointing departments

Data Sharing and Communication Physical set-up: Credentialing and Enrollment staff located in one office Billing Office staff located next door Provider Services staff use regular “POD” Meetings for updates between credentialing and enrollment staff Regular “Departmental Communication Meetings” are held with broad audience

Sample Communication Meeting Agenda and Attendees Provider Services Staff (Credentialing, Enrollment) Billing Staff Clinical Department Staff (Administrator, Finance Manager, Other) Regular Agenda Items: New Appointments – non-responders, missing documents, critical updates, red-flags Recredentialing – non responders, critical updates and red flags Maintenance Requests and Terminations Limited License Updates Other

Data Sharing and Communication Cont… Restricted System Access is granted to key staff in Billing and in the appointing departments View scanned documents of privileges, licensure and certifications View provider enrollment effective dates System access is limited to the person’s department and by the content allowed to be viewed

Key Information that may impact Credentialing or Enrollment turnaround times “Red flags” in credentialing file may delay hospital approval process and health plan enrollment. Enrollment applications cannot be submitted without a hospital letter attesting that the provider has been or is scheduled to be appointed by committee at the hospital. Date of committee required on letter Providers not eligible for U.S. board certification or providers who did not obtain board certification may encounter enrollment issues.

Key Information that may impact Credentialing or Enrollment turnaround times Cont… BWH policy does allow applicants for appointment w/o a valid DEA to sign a waiver agreeing not to prescribe Health plans require applicants to have a valid DEA with a Massachusetts address (or address in the state where the provider will be practicing).

Questions? Gwen Gilchrist ggilchrist@partners.org 857-307-0840 Kate Powers, CPMSM kdpowers@partners.org 857-307-0843 Joanna Hazell jhazell@partners.org 857-307-0841