Delegated Credentialing: Do You Know Where to Start?

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Presentation transcript:

Delegated Credentialing: Do You Know Where to Start? 2017 WAMSS Conference, April 26, 2017 Carrianne Dockter, CPCS, CPMSM Manager, Delegation Oversight, Molina Healthcare, INC

Your Presenter Carrianne Dockter CPCS and CPMSM Certified 17 years Credentialing experience, 13 years in Managed Care 13 years Delegation Oversight Manager, Delegation Oversight of Molina Healthcare’s Corporate team

Delegation: What Is It? NCQA: Occurs when the organization gives another entity the authority to carry out a function that it would otherwise perform Medicare Advantage: A business relationship between the organization and a first-tier, downstream and/or related entities to perform certain functions that otherwise would be the responsibility of the organization to perform

Delegation: Who Benefits? Health Plans: Less Credentialing duplication Increased Provider satisfaction Provider Groups: Quicker Health Plan Enrollment Faster Reimbursement

Delegation: Are You Ready? Regulatory Requirements: Managed Care business needs NCQA vs TJC Medicare Advantage Requirements Medicaid Requirements

Delegation: Are You Ready? Panel Size Requirements: 100 or fewer 100 or more

Delegation: Are You Ready? Policy Requirements: Policies vs Bylaws Draft vs Approved

Delegation: Are You Ready? File Processing: Medicare/Medicaid Sanctions Board Certification DEA Certificates Privileges and Peer References

Delegation: Are You Ready? Documentation: Verifications vs Checklists

Delegation: Are You Ready? Approval Timeframes: 180 days 365 days 120 days

Delegation: Are You Ready? Approving Committees: Board, MEC, and Credentialing Committee First Committee/Last Committee

Delegation: Are You Ready? Appeals: Multi Level Single Level

Delegation: Are You Ready? Ongoing Monitoring: License Sanctions OIG/SAM State Medicaid exclusion lists Continuous Query

Delegation: Are You Ready? Site Visits: Existing requirements, New NCQA Standard: MED 4 TJC and DNV Certifications

Delegation: Are You Ready? Sub Delegation: Delegation Agreements Audits and Oversight NCQA Certifications

Questions?