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TRANSCRIPT
Nursing Facility Credentialing through the CVO Overview and Updates to the Availity Portal
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Agenda
• Background • CVO Credentialing for New Providers • Availity Log-In & Instructions • Credentialing Application Step by Step & Portal Updates • Frequently Asked Questions
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Background
• Texas Government Code (TGC) 533.00251(e) requires HHSC to develop credentialing and minimum performance standards for NF providers seeking to participate in STAR+PLUS. During 2017, HHSC convened a stakeholder workgroup comprised of NF providers, NF provider associations, MCO representatives, MCO associations, consumer advocates, and HHSC staff. The workgroup developed the credentialing standards. The minimum performance standards are currently under development and will be included in a future amendment.
• Please note the NF significant traditional provider provision expired
in contract February 28, 2018.
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Medicaid Managed Care Contract Changes (UMCC) HHSC amended the Medicaid managed care contracts to allow MCOs to only contract with a NF that has a valid certification, license, and contract with HHSC, and that meets the NF credentialing standards outlined in the UMCM Chapter 8.6 (section 8.1.4.4 of the UMCC and STAR+PLUS contracts). • According to section 8.1.4 of the UMCC and STAR+PLUS contracts, the STAR+PLUS MCO must enter
into a provider contract with any willing NF provider that is Medicaid-certified, licensed and contracted with HHSC; that meets the NF credentialing standards and minimum performance standards in UMCM Chapter 8.6, and agrees to the MCO’s contract rates and terms. MCOs must comply with the rate requirements set forth in UMCC 8.3.9.4. A STAR+PLUS MCO is prohibited from contracting with a NF if the NF does not meet credentialing standards. A STAR+PLUS MCO may refuse to contract with a NF if the NF does not meet the minimum performance standards in UMCM Chapter 8.6.
• Credentialing was also added to the UMCC section 8.3.9, STAR+PLUS Expansion section 8.1.47, and
STAR+PLUS MRSA section 8.1.48. NF Providers must meet all of the state licensure, certification, and contracting requirements, as well as the NF credentialing standards in UMCM Chapter 8.6 for providing the services in Attachment B-2.2, “STAR+PLUS Covered Services.” An MCO may refuse to contract with a NF if the NF does not meet the minimum performance standards in UMCM Chapter 8.6.
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Uniform Managed Care Manual Changes (UMCM)
HHSC amended UMCM Chapter 8.6, replacing the current language in section 2.13.1 that requires MCO to deem nursing facilities. Start Date, Deadline, and Allowances for Deeming
• UMCM Chapter 8.6 section 2.13.1 sets a start date of April 1, 2018 when MCOs must begin using
the credentialing standards listed in section 2.13.1 to credential NFs seeking to participate in STAR+PLUS. MCOs have until December 31, 2018 to complete credentialing of all NF providers that were in its network from April 1, 2018 forward.
• UMCM Chapter 8.6 sections 2.13.1 (a) and 2.13.1 (b) describe when an MCO is allowed to deem NFs. – April 1, 2018 through December 31, 2018. The MCO may deem a NF to have met the MCO’s credentialing
standards if: • In the case of a skilled nursing facility (SNF), the SNF is already credentialed for its Medicare products
and the Medicare SNF credentialing criteria includes all of the STAR+PLUS NF state-identified credentialing standards in section 2.13.1 (c); or
• The NF is Medicaid-certified and licensed by and contracted with HHSC. – December 31, 2018 - forward. The MCO may deem a NF to have met the MCO’s credentialing standards if:
• In the case of a SNF, the SNF is already credentialed for its Medicare products and the Medicare SNF credentialing criteria includes all of the STAR+PLUS NF state-identified credentialing standards in section 2.13.1 (c).
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Deemed vs. Not Deemed Nursing Facilities
• MCOs asked NFs to perform a self-assessment to determine if they are already credentialed with their STAR+PLUS MCOs through their MMP or Medicare Advantage contracts. If the answer is yes, they will be deemed credentialed by those respective MCOs and will not be required to go through the credentialing process at this time.
• MCOs began sending notifications in May 2018 to any NFs who will be deemed credentialed and are not required to complete the credentialing process at this time. Any provider who will need to become credentialed will receive a letter from Aperture with instructions on how to begin the credentialing process beginning in May.
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Credentialing Standards Credentialing Standards The MCO must ensure and maintain documentation showing that the NF meets the following STAR+PLUS NF credentialing standards listed in UMCM Chapter 8.6 section 2.13.1 (c): • The NF has completed the MCO credentialing application, which includes but is not limited to:
– demographic forms, with supporting documentation, – requests for provider disclosure of all federal or state NF sanctions and penalties for the most recent three
years, and – the most recent HHSC inspection/survey.
• The NF has a valid Texas NF license, • The NF has a Medicare or Medicaid certification, • The NF has a Clinical Laboratory Improvement Amendment (CLIA) Certification or CLIA Certificate of
Waiver, • The NF is not listed on the following websites as excluded from participation in any federal or state
health care program – HHSC-OIG exclusions, and – HHSC-OIG Exclusion Search; and – The NF’s enrollment has not been terminated or its Medicaid provider contract cancelled by the HHSC-OIG.
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Expedited Credentialing Complete Application for Expedited Credentialing • The UMCC 8.1.4.4.1 requires MCOs to consider a NF Change of Ownership (CHOW) as eligible for
expedited credentialing, and to process claims from the provider as if it was a network provider no later than 30 calendar days after receipt of a complete application, even if the MCO has not yet completed the credentialing process. The intent of UMCC 8.1.4.4.1 is that the provider is paid at network rate by the MCO within 30 calendar days of submitting the proper paperwork for credentialing, regardless of whether the credentialing process is complete or the contract is executed. The provider is then at risk of recoupment for the difference between in-network and out-of-network rates, should the contract not be fully executed.
• UMCM Chapter 8.6 section 2.13.1 (d) outlines the required items a NF undergoing a CHOW must submit
to the MCO for an application of expedited credentialing to be considered complete. Section 2.13.1 (d) requires a NF provider’s complete application for expedited credentialing to include all items listed as STAR+PLUS NF state-identified credentialing standards in section 2.13.1 (c), except for the CLIA Certification or CLIA Certificate of waiver. HHSC made this exception, because the CLIA application can take several weeks to process, which would delay expedited credentialing. The MCO must ensure that the NF submits its CLIA Certification or CLIA Certificate of Waiver to the MCO within 84 calendar days from the submission date of the NF’s complete application for expedited credentialing.
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Who are Aperture & Availity?
• Aperture is the nation’s largest Credentialing Verification Organization (CVO) that performs Primary Source Verification (PSV) on behalf of MCOs. Aperture operates nationwide and also manages several other national, state based and specialty-based unified credentialing programs. Aperture is National Committee for Quality Assurance (NCQA) Certified and Utilization Review Accreditation Commission (URAC) Accredited for more than 10 years.
• PSV is the verification of a provider’s reported qualifications by the original source or an approved agent of that source.
• Availity serves as the online credentialing application submission portal.
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Options for Submitting NF Credentialing Applications • Option 1 - Submit an application through the Availity online portal
(preferred) • Option 2 - Submit a paper application directly to your health plan.
MCOs have created a shortened version that will be available through your MCO or Availity by request.
• Option 3 – Email your application to Aperture through secure email at [email protected] (Nursing Facilities only).
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CVO Credentialing for New Providers
Step 1
•Provider contacts desired MCOs to begin contracting
•/credentialing •Process
•If you are currently contracted with an MCO(s), you should receive a letter letting you know you will need to complete credentialing.
Step 2
•Providers will receive communication from Aperture with instructions on completing the credentialing application either through Availity or paper. Aperture will allow 60 days for an application to be submitted. Reminders will be sent every 15 days.
Step 3
•Once the application is received, Aperture may reach out to obtain materials required to perform PSV.
•Step 4
•Once PSV is complete, Aperture will send the PSV results to the MCO and the application will move forward to the MCO Credentialing Committee for review. The MCO will notify the provider of the Committee results and walk through next steps.
Please note that providers could receive application requests from Aperture on behalf of each plan. If an application is current, you may contact Aperture to let them know you already have a complete application on file and you will not need to complete the application multiple times.
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Aperture Application Gather Letters The name and location of the facility on the Aperture letter should match the name and location of the facility you are credentialing through Availity or filling out on your application.
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Receipt of Multiple Application Gather Letters from Aperture • Next steps if you receive multiple application gather letters and your
previous application was submitted within 120 days of receipt of the letter:
• Scan the letter and email to [email protected] • Advise that the application was previously submitted for a TAHP
MCO and you wish for Aperture to use it for the new request. • Attach any recently renewed credentials that pertain to the
application (license, insurance, etc)
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Re-Credentialing Process
• Nursing Facilities must be credentialed every three years. • The re-credentialing process mirrors the credentialing process,
however, Aperture will notify the NF 6 months in advance of the single re-credentialing due date. Aperture will allow 60 days for an application to be submitted. Reminders will be sent every 15 days.
• The re-credentialing date for all MCOs will be the earliest date the facility is due for re-credentialing with any MCO.
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NF Credentialing Timeframes
60 Days
• From the date of receipt of Aperture’s application gather letter, providers have 60 days to complete their application through the Availity portal or complete the shortened NF credentialing application with the bar-coded letter. NFs will receive alternating letters and phone calls every 15 days.
30 Days
• Once Aperture has received the provider’s application, they typically perform Primary Source Verification (PSV) and return the results to the MCO in approximately 30 days and a shorter timeframe for expedited requests.
30 Days*
• MCOs typically perform credentialing in approximately 30 days after the receipt of a complete credentialing application. Credentialing is performed faster for expedited events. *Various factors can impact this estimate.
90 Days
• Per the UMCC, MCOs have 90 days to complete credentialing from the date of receipt of a complete application. Per the UMCM, MCOs must perform expedited credentialing within 30 calendar days of the receipt of a complete application for NFs.
Multiple payers One website One log-in Secure, compliant network No cost
The Availity Portal
INSIGHT Access many payer-specific tools and third-party applications quickly using Availity’s single sign-on (SSO) links. Embedded right at the point of need, open these tools without having to log in separately.
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Get registered
1. Go to www.availity.com 2. Select REGISTER at the top right of
the page. 3. Select Providers as the registration
type. 4. Complete the registration process.
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You’ll need… • Basic organization information • An individual email address • Tax ID • NPI (unless exempt) • Details for two valid patients
– First and last name – Member ID – DOB
• Check payment information (optional)
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First time log in
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Use temporary password Enter and re-enter new password Set three security questions and answers
1. Go to www.availity.com 2. Click LOGIN at the top right of the page.
TIP: It can sometimes take up to seven days for an application to be approved and a temporary password sent.
Accessing Provider Credentialing
Click My Providers | Provider Credentialing.
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Provider Credentialing role
Administrators must assign the Provider Credentialing role to themselves as well as other users who will need access. 1. On your My Account Dashboard, click
Maintain User. 2. Locate and click the name of the user who
needs the access. 3. Next to the name of the organization, click
View/Edit. 4. Locate and select the check box next to the
Provider Credentialing role. 5. Click Save. Note: You will need to logout of the account for the change to take effect.
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Tips for completing an application • To start a new application, click Credential a Provider on the Provider Credentialing
dashboard. • Fields with a red asterisk (*) are required. All other fields are optional. • Information can be saved using the button at the bottom of each page. Click the dropdown
option next to Continue and click Save. – Once saved you can return to the application at a later time to pick up where you left
off. • Documents you will need prior to completing the application:
– NF License – NF Insurance Certificate (if applicable – not required for STAR+PLUS but may be
required for SN – check with MCO). – HHSC survey (2567)
• Plan of Correction • HHSC Cover Letter(s)
– NF Clinical Laboratory Improvement Amendment (CLIA) or CLIA Waiver
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Credentialing a NF, SNF Provider
• Start the process with basic information.
• Single application for multiple health plans.
• If the NPI matches any of Availity’s records, the information is pre-populated in some fields.
• When selecting a specialty you can narrow the list by typing part of the specialty name or part of the taxonomy.
• You can add additional specialties, if needed.
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Facility
MCOs
NPI
Primary
Secondary
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The sections needed when credentialing a Facility
Business name, legal name and TAX ID must match the W9
Texas contracted Medicaid Number
• In the Facility Information section: • Answer Yes to “Are you a
participating Medicaid Provider?” then add your Texas contracted Medicaid Number.
• Select a State from drop-down • Add additional Medicaid
Numbers if applicable • Complete the NF application
utilizing the yes/no questions, when applicable.
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Medicaid Contracted Number
Insurance Coverage
• In the Facility Information section: • Insurance Coverage is not
required for STAR+PLUS credentialing
• It is recommended to be submitted, if available
• If the NF is also contracted separately as a SNF for MMP or other Medicare Advantage contracts, then insurance may be required
• Check with your MCOs regarding SNF Credentialing Requirement
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Business Contact
In the Facility Information section, be sure that the Credentialing Contact for the Business is the person who should be the point of contact for the MCOs. • This will be the contact for
questions, as well as notifications for future re-credentialing notices.
• Be sure it is someone knowledgeable about the credentialing process and the content of the application.
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Service Locations
In the Service Locations section: • Select only boxes that apply to the NF • These are informational questions that do
not impact the NF STAR+PLUS credentialing status
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Service Locations (cont.)
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distribute. 29
TIP: Only one service location is allowed per application. If other locations need to be credentialed, please submit separate applications.
Services & Practice Limitations
• Skip any questions that are not applicable • Select only those services that the NF provides
directly – not through an ancillary provider
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Services & Practice Limitations (cont.)
These are information questions not impacting the STAR+PLUS credentialing status. These questions will be removed from the Availity portal.
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Services & Practice Limitations (cont.)
• STAR+PLUS credentialing requirements include the NF either having a Clinical Laboratory Improvement Amendment (CLIA) or a CLIA Waiver.
• A copy of the CLIA or CLIA Waiver is required.
• If the NF is undergoing Change of Ownership (CHOW) then the NF has up to 84 days to submit the CLIA or CLIA Waiver from the submission of the credentialing application.
• Services should only be ones provided directly by the NF – not through an ancillary provider.
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Licenses and Identifiers
Select Add a license for this provider and complete the license questions. • NFs must have a current license in
the name of the current ownership to be credentialed.
• NFs going through a Change of Ownership (CHOW) - applications are not complete until the new license is submitted.
• A letter from HHSC verifying the NF has a current license is acceptable for NFs recently completing a CHOW.
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Disclosures Answer each Disclosure question based on current ownership. • Read through all of the disclosers
carefully. • Any question answered Yes will require
further explanation. • A text box will appear with a 500
character capacity to explain. • If more room is needed, a
separate document may be submitted with further explanation under the Attachments section.
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NFs must disclose all federal and state
sanctions and penalties for the most recent
three years.
INSIGHT Example of explanation for federal and state sanctions: Texas Administrative penalties for the 4/15/16 survey CMS Civil Money Penalties for 4/15/16 survey Denial of Payment for 4/15/16 survey - DPNA for 5/31/16 - 6/15/16
Required Attachments
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TIP: Accepted file types include TIF, JPG, and PDF. There is no file size limit.
Accreditation is not required here.
Attachments
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Current NF License or HHSC Letter verifying
current license
Not required for STAR+PLUS, but preferred - May be required for SNF credentialing
Not required for STAR+PLUS, but preferred - May be required for SNF credentialing
The most recent 2567 Statement of Deficiencies that includes the Plan of Correction and HHSC
accompanying cover letters/clearance letters will satisfy as proof of Medicare participation.
Attachments (cont.)
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distribute. 37
Only the Medicaid Letter is Required
Not Required
Not Required
Not Required
Not Required
Attach CLIA Certificate or Waiver Here
Attachments (cont.)
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The most recent 2567 Statement of Deficiencies that includes the Plan of
Correction and HHSC accompanying cover letters/clearance letters.
Current W9, part of demographic information
Not Required
Not Required
Not Required
Be sure to check the box
Attestation
Attestations may be signed by any authorized representative of the NF. • The NF can determine who is
authorized to sign for the NF.
Be sure to check the boxes Be sure to check the boxes
Credentialing Dashboard
• Search and sort the list with key information
• Statuses are color-coded • Gray - application has been
started but not submitted • Blue - application has been
submitted and is in progress
• Expand sections to view progress and history details
• Amend or terminate applications in-progress
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Credentialing Dashboard
a) Show or hide the progress of the application
b) Show or hide the history details of the application
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distribute. 41
a
b
Thank you! Contact Availity Client Services for additional assistance.
Click Help & Training | My Support Tickets or call 1.800.AVAILITY (1.800.282.4548).
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Frequently Asked Questions
1. Is it possible for Texas Health and Human Services Commission (HHSC) data to be uploaded directly to Availity for the purposes of credentialing?
Availity is an independent health care information technology company that serves an extensive network of health plans, providers, and technology partners. Availity will serve as the facility credentialing application submission portal. TAHP’s goal is to develop a data sharing arrangement with HHSC as a future phase of the CVO implementation in order to auto-populate certain data. At this time the NF/SNF must provide the information as requested. It is important to complete all required elements of an application to avoid any missing information.
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Frequently Asked Questions
2. Is there a limit on size of survey that can be uploaded? No size limit. 3. Will NFs receive a response from Availity acknowledging receipt of a credentialing application? The status of the application will be available on the Availity dashboard. Once a provider submits its application, the application will be listed as “Complete” on the dashboard. The statuses are color coded and any status application in green has been approved.
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Frequently Asked Questions
4. Can a NF be rejected for MMP credentialing, but pass STAR+PLUS credentialing? Could there be a situation where a SNF was deemed for MMP, has MMP members, but then now does not pass MMP credentialing? The credentialing standards for STAR+PLUS are the baseline requirements to execute a STAR+PLUS contract. Each MCO may have additional credentialing standards that must be met to execute a MMP or Medicare Advantage (skilled) contract. Therefore, it is possible for a NF to be credentialed for STAR+PLUS, but not meet the credentialing requirements for a MMP or Medicare Advantage (skilled) contract. MCOs already credential SNFs for their MMP and Medicare Advantage products. SNFs that currently have residents who are MMP or Medicare Advantage members have already passed credentialing for those Medicare products.
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Frequently Asked Questions
5. If the documents are good for 180 days and we are to be finished by December 31, 2018, wouldn’t it make sense that we would submit our one application in April for all plans to access over the next 6 months? The Availity system is not designed to allow users to begin completing the application prior to receiving a notification from Aperture asking them to begin the process. Completing the application prior to a request from Aperture could lead to required licenses and certifications expiring before they are due.
