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UCSF Medical Group Credentialing Workflow

UCSF Medical Group Credentialing Workflow. Thank you for muting your phones during the training. Health Plan Enrollment Process Enrollment Timelines Common Credentialing Problems Commercial vs. State/Federal Plans Tools, Reports & Resources About Medical Group Credentialing.

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UCSF Medical Group Credentialing Workflow

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  1. UCSF Medical Group Credentialing Workflow Thank you for muting your phones during the training

  2. Health Plan Enrollment Process • Enrollment Timelines • Common Credentialing Problems • Commercial vs. State/Federal Plans • Tools, Reports & Resources • About Medical Group Credentialing Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  3. Health Plan Enrollment Process Overview Provider/Department • Provider must first procure: • Medical Staff Privileges http://www.ucsfmedicalcenter.org/medstaffoffice/UCSFMembership.htm • National Provider Identifier (NPI) https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart • Complete Health Plan Enrollment Formhttp://www.medschool.ucsf.edu/medgroup/credentialing/credentialing_process/begin.aspx • Print Entire Form & sign all signature pages • Submit Form, Signature pages & Attachments to Medical Group Credentialing at box 1821 Medical Group • Review for completion of all pertinent pages, information and attachments • Scan, Populate & collate applications • Data entry in ECHO for tracking and reporting • Applications are reviewed and signed off on by Director of Credentialing Provider/Department 4. Monitor enrollment status using the Provider Enrollment Report http://www.medschool.ucsf.edu/medgroup/credentialing/reports/per.xls 5. Run TES Edit Reports Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  4. Health Plan Enrollment Process Complete Health Plan Enrollment Form The electronic form can be found on the UCSF Medical Group website at:http://www.medschool.ucsf.edu/medgroup/credentialing/credentialing_process/begin.aspx Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  5. Health Plan Enrollment Process Print & Sign All Signature Pages * PRINT ENTIRE PDF * SIGN: Hill Physician Attestation Medicare Medical Group Medi-Cal * Submit Questionnaire & All Signature Pages to ‘Credentialing’ Box 1821 Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  6. Health Plan Enrollment Process Med Group Credentialing Internal Documentation Process • We keep archives of everything that goes through our office as: • Original “Hard” copies on file for anything submitted as well as • * The scanned electronic copies of submitted/in process/incomplete for both • a. applications and • b. attached documents •  Original “Hard” copies are used to create electronic archives and do data entry so the • final applications can be populated and collated in: • Echo and • FilemakerWhen doing data entry we double check all pertinent provider specific data for accuracy to ensure health plan enrollment packages are processed effectively • We also have running checklists for: • Provider Apps Received and • Submissions/In Process/Incomplete * As of September 28, 2011: 3,346 - Provider Records 16, 086 - Electronic Documents Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  7. Health Plan Enrollment Process Medical Group Reviews for completion of all pertinent pages, information and attachments Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  8. Health Plan Enrollment Process A.) Medical Group saves electronic copies of all documents then populates & collates all applications from the materials provided. B.) Completed applications are reviewed and submitted to respective health plans. Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  9. Health Plan Enrollment Process Medical Group does ECHO data entry for all applications received and submitted for tracking and reporting Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  10. Health Plan Enrollment Process Department Specific Provider Enrollment Report http://www.medschool.ucsf.edu/medgroup/credentialing/reports/per.xls Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  11. Health Plan Enrollment Process • Enrollment Timelines • Common Credentialing Problems • Commercial vs. State/Federal Plans • Tools, Reports & Resources • About Medical Group Credentialing Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  12. Enrollment Timelines • Med Group <10 Days • Medicare: < 60 Days • Medi-Cal: <60 Days for Physicians <180 Days for AHP • HPMG/Commercial Health Plans: < 40 Days * Enrollment timelines are consistent when all paperwork is complete and all necessary supporting documentation is included with the initial submission. Incomplete applications take longer to process & have a greater probability of being rejected. * Timelines are measured in “business days” ---- General Rule of Thumb: 90 Days ---- Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  13. Health Plan Enrollment Process • Enrollment Timelines • Common Credentialing Problems • Commercial vs. State/Federal Plans • Tools, Reports & Resources • About Medical Group Credentialing Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  14. Common Credentialing Problems • Medicare deactivations for not billing • Not billing within 30 days of enrollment or one fiscal year after initial billing • Provider tries to bill through a group they are not linked to • Charge entry errors • Incomplete packages, (provider information and/or attachments) • Untimely Follow-up • Medicare Specialties only recognize primary specialties • Data in ECHO has to be accurate (privileges are linked to our process) • Staff can be signed up for the roster to double check information • TES Edits: Departments are responsible for running these • Michael runs it to make sure Medi-Cal PINs are entered after 2 months • Working these TES reports prevent the loss of billable revenue due to exceeding retrobillable time frame Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  15. Health Plan Enrollment Process • Enrollment Timelines • Common Credentialing Problems • Commercial vs. State/Federal Plans • Tools, Reports & Resources • About Medical Group Credentialing Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  16. Commercial vs. State Health Plans Commercial Enrollment: HMOs: Delegate through HPMG • HPMG Attestation Form & CV PPOs: Delegated through UCSF Med Group • Comprehensive Roster (specialty HMOs that don’t go through HPMG delegate through MG) Updating/Revising Enrollments: • All are directly with health plan via fax/email using UCSF Provider Profile • State/Federal • Enrollment: • Providers are directly enrolled using plan specific applications • Updating/Revising Enrollments: • Same as the enrollment process. • Office visit/consult LOAs are completed by the UCSF Medical Group Contracting Office at (415) 476-4048. • Hospitalization LOAs are completed by the UCSF Medical Center Health Plan Strategy and Contracting Office at (415) 353-9020. Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  17. Health Plan Enrollment Process • Enrollment Timelines • Common Credentialing Problems • Commercial vs. State/Federal Plans • Tools, Reports & Resources • About Medical Group Credentialing Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  18. Tools, Reports & Resources • UCSF Comprehensive Roster • Distributed Predominantly to Health Plans by Michael DeLane delanem@ucsfmg.ucsf.edu • Includes New, Inactive & Providers with Amended Profiles • DRQ Report • Managed by Roy Cortez & Michael DeLane Roy.Cortez@ucsfmedctr.org • Weekly Correspondence of Outstanding Credentialing Issues • Provider Enrollment Report • Updated weekly http://www.medschool.ucsf.edu/medgroup/credentialing/reports/per.xls • Contains Health Plan Enrollment Statuses for all Active Medical Group Providers • Medical Group Credentialing Newsletter • Distributed monthly by Joaquin Castillo Arana aranaj@ucsfmg.ucsf.edu • Medical Group Credentialing Contacts • Michael DeLane, Joaquin Castillo Arana, Justin Lewis • Email is the preferred method of communication as all requests and correspondences are time stamped and can be tracked for efficiency accordingly. Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  19. Tools, Reports & Resources • Medical Group Website Redesign • Update Credentialing Web Query • Currently In Development of Application Portal Forthcoming Changes to Medical Group Credentialing Resources Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  20. Health Plan Enrollment Process • Enrollment Timelines • Common Credentialing Problems • Commercial vs. State/Federal Plans • Tools, Reports & Resources • About Medical Group Credentialing Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  21. UCSF Medical Group Credentialing 1635 Divisadero Street, Suite 625 San Francisco, CA 94115 Michael DeLane - Director of Credentialing 415.476.4029 – delanem@ucsfmg.ucfs.edu Joaquin Castillo Arana - Operations & Compliance Manager 415.476.1804 – aranaj@ucsfmg.ucsf.edu Justin C. Lewis - Credentialing Analyst 415.476.4061 – lewisjc@ucsfmg.ucsf.edu • We serve the departments, divisions and specialty clinics of the UCSF Medical Center • Manage enrollment for more than 2,100 UCSF Medical Group health care providers with approximately 300 contracted health plans • Report on enrollment status’ of those provider enrollments • Trouble shoot problematic enrollments • Provider ID assignment for hospital based providers Prepared by the UCSF Medical Group Credentialing 2011 – 415.476.4007 - http://www.medschool.ucsf.edu/medgroup/credentialing/index.aspx

  22. UCSF Medical Group Credentialing Provider Health Plan Enrollment Training Thank you for your time.

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