Community Care Network of Virginia Medicaid Medallion II Expansion Forum April 17 & 18, 2012

1. Community Care Network of VirginiaMedicaid Medallion II Expansion ForumApril 17 & 18, 2012

2. Discussion Agenda • CCNV Credentialing Who and What We Are? • Terminology • Credentialing Program Purpose –Why Do We Credential? • Delegation • Credentialing for the DMAS Expansion • Resources • Questions • Questions

3. CCNV Credentialing:Who and What We Are? CCNV Network at a glance • 430 CCNV Total Network practitioners • 313 PCPs – 61 identified for expansion- approx 20% of Network • 117 SCP • 105 practice locations in Virginia Credentialing Department • 7 FTEs plus Director • 55 years of combined credentialing experience • Certified Credentialers CCNV Credentials Committee • 9 network practitioners • Meets monthly and reports to CCNV Board of Directors NCQA Accredited Credentials Verification Organization • Accredited for 12 consecutive years (2001-2013) • Last review November 2011-CCNV received a score of 100%

4. Terminology Privileging- the process of the verifying the clinical competencies of a practitioners requested scope of practice and or procedures as outlined and approved by the centers Board of Directors Credentialing- the process of verifying the clinical competency, experience and “credentials” of a practitioner. Once a practitioner has been credentialed by CCNV – in a delegated relationship- the enrollment process can begin. Enrollment- the process of submitting the committee approved practitioner plan information to a health plan. Once enrolled a patient can choose the practitioner from a Plan Directory.

5. Credentialing Program:Why Do We Credential? We Credential our Health Centers Providers because: • Required for a Health center in order to be deemed under Federal Tort Claims Act ( FTCA) • Assures highest quality of care and ensures demonstration of clinical competency of practitioners • Protects health centers and patients • Supports Federal Health Plan Delegation requirements • Meets CMS & NCQA, BPHC (Pin 2002-22) FTCA Standards and Medicare/Medicaid Standards for Participation • Satisfies Managed Care Plans network requirements

6. Delegation- Defined Definition: When an organization (MCO) “delegates” all or some aspects of the credentialing process to an outside (CCNV) organization What “Delegation” Means for Our Health Centers • CCNV has received the delegated authority to review and approve providers for MCO participation • Health centers have to submit documentation one time, only to CCNV • Health centers must understand monthly Credential Committee schedule and deadlines for submission of materials

7. Delegation-Advantages Health Center perspective: • Streamlined enrollment process for practitioners-30 and 45 days versus traditional non delegation timeline of 180 days or more • Focused contact person to resolve directory/billing discrepancies CCNV perspective: • Ensures contractual agreement requirements are met • Mirrors established Health Plan Credentialing standards dictated by their Accreditation type • Must perform the functions performed by the MCO’s internal approval process • Focused contact person to resolve directory/billing discrepancies Health Plan perspective: • Ease of Enrollment activities • Reduction of Administrative staff and paperwork-applications/storage resources • Health Plans reserve the right to Approve or Deny any practitioner-regardless of CCNV’s Approval. In short they have the last say • Focused contact person to resolve directory/billing discrepancies

8. Credentialing for the DMAS Expansion-Delegation - CCNV Specific Roles Credentialing and enrollment processes CCNV completes • Third party payer tracking and follow-up. • Obtain Provider ID numbers and effective dates • Track and Update Demographic changes etc • Recredentialing Management- timely • Semiannual credentialing reporting • Directory calibration • Annual Delegation audits by MCO’s to ensure compliance • Policy and procedures reviewed • File Audits • Quality reporting to the MCO • Form and content of Credentials meetings via minutes review • Initiation of quality improvements projects • Ongoing monitoring and sanction review

9. Credentialing for the DMAS Expansion Health plans who have NOT delegated credentialing to CCNV • Anthem Health plans who have delegated credentialing to CCNV • Amerigroup Virginia HMO • Carilion Majesta Care • Optima Family Care Medicaid • Southern Health “CareNet" • Virginia Premier HMO

10. Credentialing for the DMAS Expansion

11. Credentialing for the DMAS Expansion-Network Review- Pre July 1 CCNV tasks Audit practitioner roster by center with Health plans • Ensure all practitioners are accurately set up with each health plan • Collect missing numbers and effective dates if applicable Audit practitioner roster by Health plans with center • Collect current roster from Health plan and reconcile as necessary • Ensure all practitioners are enrolled per credentialing ( i.e. PCP versus SCP enrollment) Coordinate and Communicate with centers and Health plan contact to ensure resolution of requests

12. Credentialing for the DMAS Expansion-Network Review- Pre July 1 Health Center tasks Be proactive in Recruiting • Identify and communicate to CCNV all potential new hires and resignations • Timelines –Completed-Credentialing applications need to be received no later than 7 days before Credentialing Committee Meeting • 2 Credentialing Committee dates remain for July 1 deadline. May 18 and June 15 • Board dates are May 24 and June 21 • Communicate all changes n providers (additions, terminations, etc.) to CCNV immediately to ensure timely processing

13. Credentialing for the DMAS Expansion Education efforts • Conduct in service training for Credentialing team regarding DMAS expansion requirements • Educate centers of web site resources directory and new E status capabilities • Remind Centers of Credentialing and Enrollment timelines

14. Credentialing for the DMAS Expansion-Post July 1 – CCNV Tasks Communicate and track gaps • Inform centers of follow up plan of network gap • Collect Id’s and effective dates from health plan • Credentialing Database updated- Estatus solution for centers • Contract Director assists with gap resolution Re Audit 30 days prior to July 1 deadline

15. Resources for Our Health Centers Implementation of enhanced technology • E Status convenient and expedited status look up • Web site • Frequently Asked Questions ( FAQ’s) • On Line Documents • On Line current Provider Directory by Site • Access to CCNV Policy and Procedures • Contact us- changes etc • Future enhancements • E Apply- allows remote application completion that feeds directly into the Credentialing Database • On Going Web site user friendly resources

16. QUESTIONS? Please visit our web site: WWW.CCNVA.COM Christopher Stamnas, CPCS804-237-7686-EXT 1214 Cstamnas@CCNVA.com