the provider enrollment process · introduction the enrollment process is performed for several...
TRANSCRIPT
The provider
enrollment process
Healthy Blue
Introduction
The enrollment process is performed for several reasons:
• To ensure that Healthy Blue has accurate information
about providers and practices.
• To verify providers are in good standing.
• To confirm providers meet enrollment requirements.
• To validate qualifications.
To begin the provider enrollment process, each provider
must complete the Provider Enrollment Application and
submit required documentation.
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New web page and email contacts
for provider enrollmentHealthy Blue streamlined the provider enrollment process. We have
developed a new web page and email addresses to ease the enrollment
process. Our goal is to reduce the number of incomplete applications.
As of February 15, 2019, the email address [email protected] is
no longer supported. Please use the following website and email
addresses:• Provider enrollment —https://web.southcarolinablues.com/providers/
providerenrollment.aspx• Initial enrollment applications — [email protected]
• Returning documentation — [email protected]
• Provider demographic updates — [email protected]
• Recredentialing — [email protected]
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New web page and email contacts
for provider enrollment (cont.)
Initial enrollment applications — [email protected]
• Credentialing a new provider
• Adding a midlevel provider
• Enrolling a new practice
• Telemedicine applications
• Credentialed provider affiliating with a new practice
• Completing a group application
Returning documentation — [email protected]
• All requested information from the above applications
4
New web page and email contacts
for provider enrollment (cont.)
Provider demographic updates — [email protected]
• Adding a satellite location
• Change address or other demographic information
• Out-of-state or out-of-network requests
• NPI updates
Recredentialing — [email protected]
• Recredentialing a provider
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New website for provider enrollment
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Visit the newly updated enrollment
website at:
https://web.southcarolinablues.com/
providers/providerenrollment.aspx
New website for provider
enrollment (cont.)
• If you need help with the provider enrollment process, submit questions using the Provider Enrollment Assistance Form. You will receive a response within two business days.
• This form can be located by selecting New Provider/Initial Enrollment.
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New website for provider
enrollment (cont.)
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Navigate to the bottom of
the page and select
Contact Us.
New website for provider
enrollment (cont.)
Why did we decide to use this
form rather than free form
emails?
• Free form emails often did
not contain enough
information for us to answer
your questions.
• This form contains all of the
information needed to
accurately and efficiently
respond to your inquiries.
A representative will contact you
within two business days.
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Provider enrollment process
To ensure that you are submitting a complete provider enrollment packet, please visit https://web.southcarolinablues.com/providers/ providerenrollment.aspx. Here, you will find instruction on how to:
• Enroll a new medical provider.
• Enroll a behavioral health provider.
• Enroll a dental provider.
• Update demographic information.
• Recredential an existing provider.
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Provider enrollment process (cont.)
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To enroll a new
provider, select
New
Provider/Initial
Enrollment.
Provider enrollment process (cont.)
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Follow the steps on this page to
complete the provider enrollment
process.
1. Select the provider type to access
the checklist.
2. Complete all necessary forms.
3. You will need contract pages for
each network you are applying for.
Select Request network contract
pages and they will be sent directly
to you.
4. Submit completed enrollment
applications to
We will begin the enrollment process
when all the items are received and
complete.
Provider enrollment checklist
Checklists are fillable and
include hyperlinks to the
actual forms.
We will begin the enrollment
process when all the items
are received and complete.
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Provider enrollment checklist (cont.)
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We have included a Provider
Enrollment Checklist in the
application.
This checklist outlines the forms
required for each provider type.
Midlevel providers are required
to complete the full application
for Medicaid. An abbreviated
two-page application is required
for commercial networks.
Provider Enrollment Application
• The Provider Enrollment
Application replaces the S.C.
Uniform Credentialing
Application.
• Select all networks that the
provider wishes to join.
• Completed applications
should be faxed to
803-870-8919 or emailed to
Provider.Blue.Enroll@
bcbssc.com.
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Provider Enrollment
Application (cont.)This page requests information regarding the
practitioner's personal information,
medical/professional education and
professional training.
Section 1:
• ECFMG # is the number assigned to
foreign medical graduates.
• The date the provider will start working
for your practice is required.
Section 3:
• If this section is not applicable, you must
select the box that says Check here if
entire section below is not applicable.
Please note that all pages now require
provider initials and date.
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Provider Enrollment
Application (cont.)This page requests information regarding the practitioner's state license, specialty board certification and hospital privileges.
• Section 5
– If this section is not applicable, you must check the box.
– Education and specialty must match.
• Section 6
– Include a Do Not Admit Plan (if applicable). This must be a written description of the hospital admitting arrangement
– Certified registered nurse anesthetists (CRNAs) are not required to complete this section.
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Provider Enrollment
Application (cont.)
• This page requests information regarding the practitioner's work history.
• Five year work history must be in the month/year to month/year format.
• Do not include the day. If no end date, indicate to present.
• You are required to explain any gaps longer than six months.
• A CV cannot be used in place of this section.
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Provider Enrollment
Application (cont.)
• This page requests information regarding the practitioner's primary practice location, office hours, billing address and patient population demographics.
• Section 8 — Please indicate if you would like the provider to be listed at this location in our directory.
• Please include the practitioner’s Medicaid ID number if they are applying for the Medicaid network.
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Provider Enrollment
Application (cont.)
• This page requests information regarding the practitioner's additionalpractice locations, office hours, billing address and patient population demographics.
• If the practitioner has no additional locations, please check the box at the top of the page.
• If the practitioner has several additional locations, make copies of this page and complete for each site.
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Provider Enrollment
Application (cont.)
Pages 4 and 5 are critical for ensuring practitioners are listed accurately in our Provider Directory.
A practitioner can be affiliated with as many locations as needed. However, you should only check this box if the practitioner is actively taking appointments at a location. If this box is checked, this practitioner will display at this location in our directory.
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Provider Enrollment
Application (cont.)
Patient population information is also displayed in the
Provider Directory. Please make sure this information is
accurate.
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Provider Enrollment
Application (cont.)
• This page must be completed by the provider.
• In order for the enrollment process to begin, boxes checked Yes must be accompanied by a detailed written explanation.
• Attachments can be included, but a written explanation is also required.
• All answers will be validated, confirmed and reviewed.
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Provider Enrollment
Application (cont.)
• This page must be
completed by the provider.
• Use this page to respond
to any questions where
you indicated Yes on the
previous page.
• Prewritten explanations
may be attached in place
of this page being
completed.
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Provider Enrollment
Application (cont.)
• This page must be signed and dated.
• Electronic signatures are acceptable for this page.
• Signature date must be less than 150 days old.
• Submit completed application and required forms to Provider.Blue.Enroll@ bcbssc.com or fax them to 803-870-8919.
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Required documents —
South Carolina Medical License
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The license must not expire within 30 days of application
submission.
Required documents —
DEA Certification
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The license must not expire within 30 days of application
submission.
Required documents —
Proof of malpractice insurance
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• Malpractice must be a minimum of
$1 million/$3 million. This can be
reached by combining policies.
• Must not be within 30 days of
expiring.
• Physician’s name must be on the
face sheet.
Required documents —
Electronic Claims
Filing Requirement
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Required documents —
Terms and Conditions for
Electronic Payment
30
Electronic signature
is acceptable.
Required documents —
EFT and ERA Enrollment
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Electronic signature
is acceptable.
Required documents —
IRS document
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Required documents —
authorization to bill
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Required documents — CLIA
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Required documents — Nurse
Practitioner Information Form
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Additional forms required for Medicaid —
Nurse Practitioner Protocol
• This document
allows the office to
identify preceptor(s)
for the nurse
practitioner.
• The supervising
physician must be
an approved
in-network
physician.
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Additional Forms Required for Medicaid —
Nurse Practitioner Protocol (cont.)
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Additional Forms Required for Medicaid —
Nurse Practitioner Protocol (cont.)
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Additional Forms Required for Medicaid —
Disclosure of Ownership
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This is the first page of
seven pages that may
need to be completed.
Dental credentialing• Dental credentialing is for the
participating dental and state dental plus networks.
• Other plans that use the Participating Dental Network include:
– BlueCross Federal Employee Program (FEP)
– BlueDentalSM
– FEP Basic and Standard
– GRID members
• For initial credentialing, use the South Carolina Dental Credentialing Application. This form can be located under the checklist for doctor of dental surgery (DDS) and doctor of dental medicine (DMD).
• Recredentialing occurs every three years. Use the same credentialing application for this process.
• Fax completed applications, documentation and contract signature pages to 803-870-8919.
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Behavioral health credentialing
Companion Benefit Alternatives
(CBA) coordinates credentialing for
mental health practitioners. CBA is
a separate company that provides
mental health and substance abuse
benefits on behalf of BlueChoice
HealthPlan. Complete these steps
to enroll with CBA. Return
completed applications by mail or
fax.
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Behavioral health credentialing
(cont.)
• A separate application is
required for behavioral
health providers.
• Please complete this
application and return to
CBA.
• If you have questions,
please contact CBA at
800-868-1032, ext. 25744.
• Return completed
applications by mail or fax.
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Behavioral health
credentialing (cont.)In late spring 2019, behavioral health providers will be able to apply
via an online application at
www.companionbenefitalternatives.com.* If you have questions,
please contact [email protected].
* This link leads to a third-party site. That organization is solely
responsible for the contents and privacy policies on its site.
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New option for
provider credentialing• If you want to check status of a previously submitted application, or if you
have received correspondence on your application and have questions, you can now use the voice response unit (VRU).
• The recording will then give you two options to choose from:
– To begin the provider enrollment process, please go to the Provider Enrollment sections of SouthCarolinaBlues.com to find a Checklist of the information, documentation and required forms to be submitted to us as one Complete Enrollment Packet for consideration to join our networks. If you want to check the status of a previously submitted application, press 1.
– If you have received correspondence on your application and have questions, or need any other Provider Enrollment assistance, press 2.
• Phone lines will be available Monday–Friday from 8 a.m.–5 p.m.
• All calls received after 5 p.m. will be routed to Provider Services or a message will tell the providers to call back during regular business hours.
• There will not be a voicemail option.
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Demographic updates
• Demographic updates are
essential to the success
of your practice.
• You can make updates
easily through Medical
Directory Check Up (M.D.
CheckUp).
• Just select Let Us Know
to access M.D. Check
Up.
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Demographic updates (cont.)• This page provides instructions on
accessing and updating your information.
• M.D. CheckUp allows you to view information for all of the associated locations as well as the affiliated practitioners for each location.
• You’ll have the opportunity to update information at any time; however, we will require verification for each location on a quarterly basis, as follows:
– January 1–March 31
– April 1–June 30
– July 1–September 30
– October 1–December 31
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Demographic updates (cont.)
• This tool is available within My Insurance ManagerSM in the M.D. CheckUp. This feature allows you to seamlessly verify practice and physician demographic information. You will be able to:
– Verify — Information shown is current and accurate. Verify is the final step to confirming revisions and to attest that no further action is needed for the quarterly verification.
– Update — Once a change has been made, Update must be selected to confirm and accept the change.
– Remove Location — Enter or select a date to indicate that a location shown in the Location List is no longer active or part of the organization.
– Remove Practitioner — Enter or select a date to indicate that a practitioner is no longer participating with the specific location.
– Add Practitioner — Add a practitioner to the specific location by using the Add Practitioner search function.
– View and Edit — Access and edit location information (addresses, telephone number, fax number, hours of operation, etc.).
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Demographic updates (cont.)
Why are these updates so critical? You could be losing patients.• Keeping the provider directory accurate and up to date is essential
to the health plan and providers.
• From the health plan’s perspective, the health plan and CMS have secret shoppers to audit the accuracy of the directory. The health plan is scored on the accuracy of the information displayed in the directory.
• From the provider’s perspective, if provider data is incorrect or outdated, you could be losing patients.
• If you receive the notice to update your demographic information, please do not accept without fully reviewing the information.
• If you are not the correct person that to be reviewing this data, please send this to the appropriate person who can accurately validate.
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Demographic updates (cont.)
Common errors found during secret shopper:
• Appointment phone numbers are incorrect. Patients cannot reach the
office to make an appointment, so they choose to call another
practice.
• Practitioners are listing at a location where they do not practice. If a
patient calls to schedule an appointment with a certain practitioner,
and are told he or she is not at this location, patients get frustrated
and may choose another practice.
• Practitioners are listed as accepting new patients, but patients call to
make a new patient appointment and are told that physician’s panel
is closed. Patients get frustrated and may choose another practice.
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Demographic updates (cont.)
• The Location Details screen
shows the practice details:
– Address
– Phone number
– Fax
– Website
– Hours of operation
– Affiliated practitioners
• The Edit function allows
users to modify the
information shown.
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Demographic updates (cont.)
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If you click on Remove Location, you are
closing out that location in our system as
well as removing it from the directory.
Recredentialing
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Established providers are
required to complete the
credentialing process every
3 years.
You can access the forms
necessary to complete the
process by selecting
Established Providers/
Re-credentialing
Recredentialing (cont.)
• Our staff will notify you when it is time for you to complete this update.
• The recredentialing process consists of the South Carolina Uniform Managed Care Practitioner Credentials Update Form (5 pages). This is an abbreviated version of the Provider Enrollment Application. The following guidelines apply:
– Office/credentialing contact, phone number and email address is needed.
– Hospital admitting information is required. If the provider does not admit, an admitting plan must be submitted.
– Providers will need to submit a copy of their malpractice coverage that will not expire within 30 days.
– If the provider answers Yes to any question on page 2, a detailed explanation is required.
– Signature dates on pages 2, 3 and 5 must be less than 150 days old.
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Recredentialing application
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Recredentialing application (cont.)
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Recredentialing application (cont.)
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Applications with missing documentation
• The enrollment process will only begin once all required documentation is received.
• If we receive an application that is incomplete or missing documentation, we will contact the office and/or credentialing contact listed on the Provider Enrollment Application. This notification of missing items will be made within seven days of receipt of the application.
• Outreach will be made to the provider for 60 days to attempt to collect the missing items. If missing items are not received within 60 days, the application will be returned and the enrollment process closed. A new enrollment form will be required to re-start the enrollment process.
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Applications with missing
documentation (cont.)
Why submit a complete application?
• Sixty-five percent of enrollment applications are received
incomplete.
• The enrollment process will not begin until all enrollment
items have been received.
• Even if just one item is missing, the process will not begin
until that item is received.
• The enrollment process is not started while the health plan is
waiting on missing items.
• Signature pages and effective dates for certain documents
can expire while the application is awaiting the missing items.
• Complete applications can be processed in 21 days.
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Clean application
enrollment process
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Application processing
• The effective date is the date the Credentialing Committee approves the application. Per Utilization Review Accreditation Commission (URAC) requirements, we cannot backdate effective dates.
• Once we approve your application, we will send a notification email to you within a few days of the Credentialing Committee approval. We will then send a welcome packet.
• The Credentialing Committee reviews all submitted documentation to ensure providers meet credentialing criteria. This includes a list of items that need to be satisfied according to URAC, NCQA and South Carolina Department of Health and Human Services.
• Additional state requirements must be met (for example, adequate malpractice coverage).
• The Credentialing Committee approves or denies an application based on all of the information above.
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Thank you
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www.HealthyBlueSC.comBlueChoice HealthPlan and BlueCross BlueShield of South Carolina are independent licensees of the Blue Cross and Blue
Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company,
for services to support administration of Healthy Connections.
To report fraud, call our confidential Fraud Hotline at 877-725-2702. You may also call the South Carolina Department of Health
and Human Services Fraud Hotline at 888-364-3224 or email [email protected].
BSCPEC-1180-19 March 2019