Smoky Mountain LME/MCO Credentialing Ensuring Quality Services

10/29/2014
Smoky Mountain LME/MCO Credentialing
Ensuring Quality Services
Dial this number: +1.734.746.0035 Conference ID: 216-387-414
Housekeeping
 On‐line participants MUST keep phones muted
 On‐line participants are asked NOT to place the call on hold
 On‐line participants may submit questions via the Chat function in JoinMe
 All questions will be addressed at the end of the training for in‐person and on‐line participants (take notes, reference slide #)
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Agenda
 What is credentialing?
 What is changing?
 Defining and understanding the role of the credentialing delegate
 Network development
 Credentialing processes
 Forms review
 Information and resources
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What is Credentialing?
 Process of verifying that providers are properly qualified to deliver MH/IDD/SA services
Application review
Process
Verifications
Site visit(s)
Credentialing Committee review
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What is Changing?
 Regionalization of credentialing effective Nov. 1, 2014
 Includes CenterPoint, Partners, and Smoky
 Credentialing applications for all 3 Managed Care Organizations (MCO) will be processed by Smoky (Cred Delegate)
 Applications for one MCO can be applied to another MCO under certain conditions
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Why is it Changing?
 Standardization
 Single re‐credentialing schedule
 Coordinated credentialing processes (under certain conditions)
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What Stays the Same?
 Credentialing is independently determined by each MCO
– Independent credentialing committees – Credentialing approval by one MCO does NOT guarantee approval by another MCO
 Contracting is independently determined by each MCO
– Contract approval by one MCO does NOT guarantee approval by another MCO
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How Will Eff Dates Be Established?
 Credentialing eff date = date complete application is received by Smoky (cred delegate)
 Billing eff date = date of fully executed contract with MCO
 Licensed Practitioner billing effective date = cred effective date
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Timeframes and Transition
IMPORTANT!
 Credentialing performed by one MCO prior Nov. 1 is
NOT honored by all three MCOs
 Applications received prior to Nov. 1 will be processed by the receiving MCO
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CAQH Roster Process
 CenterPoint and Smoky practitioner rosters will be merged under Smoky
– Give Smoky permission to view profile
 Partners practitioners will be rostered to Smoky
– Complete CAQH app
– Give Smoky permission to view profile
 CAQH Announcement
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What Does the Credentialing Delegate Do?
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Receive applications
Review applications
Conduct verifications
Coordinate site visits
– Conducted by MCO per catchment area
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The Role of the Credentialing Delegate
CenterPoint Network Development
Partners Network Development
Smoky Network Development
Credentialing Delegate (Smoky)
CenterPoint Cred Committee
Partners Cred Committee
Smoky Cred Committee
CenterPoint Contracting
Partners Contracting
Smoky Contracting
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Network Development
 What are the service gaps in each MCO?
– MCO specific gap analysis
 Provider Nomination Form (Provider initiated)
 Requests for Information (RFI) (MCO initiated)
 Requests for Proposal (RFP) (MCO initiated)
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Nomination Form
 Unified form for all 3 MCOs
 Must be submitted to each applicable MCO in order to be considered by that MCO
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Agency Credentialing
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Agency Credentialing con’t
 App review
– Applicants with missing information will be notified via email
– Applicant has seven days to respond to notice (2 notices max)
– If no response is received, the application will NOT be processed. Applicant and applicable MCO(s) will be notified
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Practitioner Credentialing
CIF
CAQH
App Review
• Credentialing Initiation Form (CIF) • Found on Smoky (cred delegate) website
• Council for Affordable Quality Healthcare (CAQH)
• On‐line practitioner credentialing application
• Applicants with missing information will be notified via email
• Applicant has seven days to respond to notice (2 notices max)
• If no response is received, the application will NOT be processed
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Credentialing Initiation Form Review
 Single form submitted to Smoky (cred delegate)
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Practitioner Credentialing con’t
 Licensed Practitioners (LP)
– LPs employed with a contracted agency will be considered for credentialing by each MCO that contracts with the agency
 Licensed Independent Practitioners(LIP)
Nomination Form
Network Development CIF
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Provider Changes
 Request for Change Form –
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Request to add sites/services/change address
Remove sites/services
Change of contact info
Request change of business/ownership info
Add/remove a credentialed practitioner
Note: Licensed Practitioner to Independent Practitioner transition = 20
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Request for Change Form Review
 Unified form for all 3 MCOs
 Must be submitted to each MCO in order to be considered by that MCO
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Hospital Credentialing
 Credential the organization and its facilities
– App submitted to Smoky (cred delegate) for processing
 Hospital practitioner credentialing
– Practitioners credentialed by the hospital
 Honored by the MCO
– Practitioners NOT credentialed by the hospital
 Credentialed by the MCO
 Initiate process by submitting CIF
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Re-Credentialing
 Combined schedule – Re‐credentialing conducted once for all applicable MCOs
– Based on earliest initial credentialing date  Re‐credentialing packet will be sent to the provider from Smoky (cred delegate)
– Current provider contact information
 Agencies
– All currently cred sites and services for all MCOs
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Helpful Hints
Do’s
 Keep CAQH data current
 Inform the MCO of any changes affecting agency or practitioner credentialing
 Keep contact info current with the MCOs
 Submit legible paperwork
 Do respond to info requests within required timeframes
Don’ts
 Submit incomplete or incorrect forms/applications
 Send duplicates of paper documents 24
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Key Deadlines
• When an application/request requires additional information and no response is received from the applicant within 7 days (max 2 notices), the application/request will NOT be processed
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How Do I Find More Info?
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Documents
Forms
Resources
Additional information
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Contact Us
Questions about the credentialing process? Please visit us at
http://www.smokymountaincenter.com/credentialing
Contact us at 855‐432‐9139
or credentialingteam@smokymountaincenter.com
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Resources
http://www.cphs.org/providers/be
CenterPoint Human Services
Provider Network/Network Development come‐provider/ Info
Partners Behavioral Health Management http://www.partnersbhm.org/
Provider Network/Network Development Info
http://www.smokymountaincenter.
Smoky Mountain LME/MCO
Provider Network/Network Development com/providers.asp?section=enroll
Info
Western Region Credentialing Info (Smoky)
http://web01.smokymountaincent
er.com/credentialing/
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Questions?
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