1. PPS Enrollment & Maintenance Services
Brief overview of the enrollment process for established practices using our services.

2. Getting Started with PPS
What We Need
Complete and accurate credentialing information for all new and existing providers. This information can be provided by using CAQH, existing credentialing software, spreadsheets or paper hospital applications.
Documents needed: malpractice certificate, state license(s), DEA certificate, CV and board certificate(s). All of these documents should be in CAQH which means they don’t need to be sent over separately. If they are absent from CAQH, we will discover this during our initial CAQH audit and inform the client.
Complete listing of all contracted payers, government agencies, IPAs, MSOs and PHOs. We also need to know which payers, if any, are under delegated agreements.
We prefer to receive all new provider packets at least 90 days prior to their anticipated start date.

3. Commercial Insurance Credentialing Process
Overview
Payer is contacted and initial application or request for participation is sent to payer
Provider’s request is received and Payer pulls CAQH file or standardized application
Payer begins processing provider’s file and conducting primary source verification
Provider goes to committee to be approved and payer assigns a provider number
Provider wants to participate with a commercial insurance carrier

4. The Medicare Enrollment Process
Overview
We can typically use CAQH for most of the information necessary for the Medicare application. If this is unavailable, we will request the information necessary to proceed.
All Medicare applications are submitted online to take advantage of the shorter processing time for PECOS apps.
If the provider is joining an established group, we will need the Primary & Secondary locations for the new provider, Group PTAN, group’s EIN, type II NPI and the delegated or Authorized official who will sign off on application.
Applications for new providers typically take days depending on your state’s Medicare administrator.
Provider wants to participate with Medicare

5. New Provider Enrollment Process
Enrollment Overview
Provider’s CAQH login information is provided to PPS. CAQH profile is audited and any missing documents or information is added. If provider does not have a CAQH #, we will need our enrollment form or the medical staff application completed which will allow us to complete the CAQH enrollment process.
Once we have a complete provider profile in CAQH, we then export this data into our credentialing software and initiate the enrollment process with all contracted payers.
We stay in constant communication with the payers and provide bi-weekly updates to client regarding the enrollment/contracting status for all providers.

6. The Credentialing Process
Overview
Initial request to join network is reviewed by payer and CAQH profile is accessed/reviewed.
Payer reviews network need against your specialty and location to determine if you should move forward in the credentialing process.
0-45 days
If network management confirms a need, the credentialing application is moved through to primary source verification (verifying your license, dea, malpractice, etc).
This is where a lot of applications are held up due to a payer’s credentialing backlog. This process can extend to beyond 120 days for some payers but should only take about 45 days.
Days
Once a provider’s credentialing file is approved, they are then either linked to an existing group’s payer contracts through an addendum or a new contract is offered to the new member of the group.
If a provider is joining a small practice, it’s quite possible and even likely that the new provider will be individually contracted under the group’s EIN. Group contracts are typically available to group’s with a least 4 physicians.
Linking a new provider to established group contracts only takes about days vs a new contract taking days.
Days
**Days indicated are days the application is in process**

7. Reporting
What You Receive
PPS keeps a running log of all maintenance related issues and provides a monthly report showing average time from notification to completion.
PPS continuously monitors all providers and can provide participation reports as needed. These reports are typically delivered through our HIPAA compliant file sharing platform on a weekly basis.
PPS works closely with client to ensure the division leaders understand which payers are in-network and which payers are still pending. It is our goal to have all new providers fully enrolled 30 days prior to their start date.

8. Compliance
Keys to Success
Primary Source or HR department office must notify PPS within 30 days of any malpractice cases.
Compliance and billing office must notify PPS of any sanctions or fraud allegations within 30 days.
Client must notify PPS of any changes to the contracted payer grid within 30 days of signing a new payer agreement or terminating an existing agreement.
Client must notify PPS of any changes to the roster including new billable providers, new addresses or the termination of any employed providers.

9. Summary
It is our goal to provide our clients with an efficient and cost- effective solution to the challenges of insurance credentialing.
All of our clients receive a dedicated account manager whose primary role is to ensure client satisfaction and the efficient completion of all credentialing requests.
Our service can be tailored to fit just about any organization, so please inform us if at any time our service isn’t satisfying your credentialing needs.