Payer Enrollment & Credentialing
REQUIRED DOCUMENTS
What documents are needed for insurance credentialing?
Document needs vary based on the type of provider and insurance plan. Here are a list of base documents that may be needed:
Core Documents for an individual Provider setup:
- Practitioner License(s)
- Malpractice Insurance (Certificate of Insurance)
- DEA (federal) and state CDS certificates
- Board Certification(s)
- Diploma – copy of highest level of education (required for non-MD’s,DO’s)
- Current CV (showing current employer, and all entries have mm/yy format)
- IRS Form W-9
- Current driver’s license
Other documents that may be applicable:
- ECFMG Certificate (if educated outside of The United States)
- Passport or other citizenship documents (if born outside U.S. and not previously enrolled in Medicare)
- Collaborative Agreement (required for Nurse Practitioners)
- Admitting Arrangement letter (required for providers who do not have hospital admitting privileges)
- Prescribing arrangement letter for providers not holding DEA certificate
Legal Company Document Requirements:
- IRS form CP575 or replacement letter 147C (verification of EIN)
- Business License
- CLIA Certificate
- Copy of office lease (required for therapy facilities)
- Letter of bank account verification (for Medicare enrollment)
- EFT/ERA – Banking & Routing number information for setup
Commercial Plan Services
CREDENTIALING & PROVIDER ENROLLMENT ROSTERING
Provider credentialing, the process of getting a physician or a provider affiliated with payers. This is the process that is crucial for start date and revenue flow
FACILITY CREDENTIALING & RECREDENTIALING APPLICATIONS
Complete initial file rosters and recredentialing files for all physicians, locations either delegated or individual application in order to achieve “Par” status
RECREDENTIALING &
MAINTENANCE SERVICES WITH
COMMERCIAL PAYERS
Every 2-3 years for recredentialing by payer including review of initial files/recred files/peer review
MAINTENANCE OF PROVIDER QUALIFICATIONS, BACKGROUND & ATTESTATION
(Primary Source Verification “PSV”, CAQH, DEA, License, Malpractice, etc.)
ADDRESS & LOCATION UPDATES
Address and Department Group information updates added by individual applications or by rosters either weekly or monthly
Government Plan Services
MEDICARE INITIAL
APPLICATIONS & REVALIDATIONS
Group and provider applications submitted through PECOS by surrogacy.
PECOS is the Provider Enrollment, Chain and Ownership System used by Medicare for all enrollments
NPI MAINTENANCE & STRUCTURE REVIEW
NPIs are critical to the claim payment and billing process. Type 1 and Type 2 NPIs are reviewed and updated by trained staff through NPPES, the National Plan and Provider Enumeration System
MEDICAID
INITIAL
APPLICATIONS
& REVALIDATIONS
Group and provider applications are reviewed and submitted through each individual state’s portal or by paper
Managed Care Systems Group provides our clients with the expertise to ensure that their hospital, physician and ancillary provider locations are enrolled and credentialed accurately and efficiently with all payers. We take on the complex process of credentialing providers and enrolling them in payer networks using an individual provider or delegated agreement approach.
Frequent changes to provider networks and medical staff rosters require diligent payer credentialing and enrollment activity to prevent a delay in payment for services rendered.
Our comprehensive Payer Credentialing and Enrollment services allows our clients to streamline the process, manage the wide range of payer requirements, and stay abreast of expiring enrollments and credentials.
All work is performed at the highest level of accuracy and auditing with 100% of every step being performed by experienced staff located in the United States. We specialize in individual, specialty group, or large multi-hospital health system provider entities with knowledge of delegated credentialing or individual application submission meeting standards set by either NCQA or URAC accreditation requirements.
Regular reporting is provided to the clients’ management team to keep them well informed of each provider’s credentialing and enrollment status with each payer.
