1. Understanding Payor Enrollment
8/7/ :40 AM
Understanding Payor Enrollment
Carrie Bradford, MHA, RHIA, CPMSM, CPCS
Senior Director
Professional Staff Services and Credentialing
NorthShore University HealthSystem
Evanston, IL
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

2. 8/7/ :40 AM
Payor Enrollment
Traditionally a function of the business office or finance
Completion of forms/processes to enroll providers for payment for services rendered
Best practice: should always be for providers who are your employees or are contracted for. Watch out for stark!
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

3. Payor Enrollment Definitions Government Plans Contracted Plans
8/7/ :40 AM
Payor Enrollment
Definitions
Facility and Organization Dependent
Government Plans
Medicare/Medicaid
Contracted Plans
Third Party Payors: Aetna, Cigna, BCBS
© 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries.
The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION.

4. Government Plans Medicare 101 Part A – Part B 855-I & 855-R
List of accepted providers
Paper submission vs. Electronic
PECOS (Provider Enrollment Chain and Ownership System

5. Government Plans Medicare Administrative Contractors (MACS)
Process Enrollment
Process Claims
Determined/Contracted by CMS
Medicare “opt out” lists are on MAC pages for your state

6. Government Plans Medicare Enrollment Process Paper vs. PECOS
Wait…lets not forget about location…location
Medicare provider helpline on your MAC website
Paper vs. PECOS
Leverage your software
Use the correct form, if not sure call the hotline
TAT with MAC
Claims retro back 6 months

7. Government Plans PECOS
The NPPES (National Plan and Provider Enumeration System) NPI login is a providers PECOS Log in
Provider must grant you authority to change record on their behalf. (meaninful use, pecos, nppes coming soon)
Identity and Access System of CMS designates your level of access. This is granted by your organizations Authorized or Designated Official

8. Government Plans Medicaid Enrollment State based process
Paper now evolving to electronic
Other state programs can be intertwined in this enrollment
TAT varies
Leverage your software

9. Government Plans Revalidation Requirement of the Affordable Care Act
Reduces Fraud/Waste
Cleans up the MAC mess
Once every 5 years…this is really not true in all cases

10. Contracted Plans Managed Care Contracting
Who – IPA, PHO…
What – providers/large groups
Why – for reimbursement at a GOOD rate
How – thru a contract
Where do we fit in?? NCQA….and delegation

11. Contracted Plans Managed Care Credentialing
CAQH…Council for Affordable Quality Healthcare
Data repository “Proview”
Plans must give provider a number
Data entry along with certificates
Initial and Recredential – Reattest every 120 days
Duplicative for some

12. Contracted Plans Managed Care Credentialing Delegation
Addendum to your managed care contract – READ IT
Yearly audit…even for those who have NCQA CVO cert
Checklist
Gets your providers in quickly…$$$
Rosters
Information Updates
No secondary database requirements

13. Resources Websites: List of MACS Medicare Managed Care CAQH
Medicare Managed Care
CAQH

14. Questions?
Thank you!