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

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

3. 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

5. 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 notification simultaneously when DCR is submitted
Notification allows credentialing and enrollment process to run concurrently, as appropriate

6. 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”

7. 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:
MPRN: 25838
Requested Effective Date:
7/31/2017
GENESYS:
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
Personal AHP/APP Researcher
Admin Contact
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
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8. Credentialing Process
Link to on-line application sent to provider via
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)

9. 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

10. 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

11. 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

12. 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

14. 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.

15. 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).

16. Questions?
Gwen Gilchrist Kate Powers, CPMSM Joanna Hazell