CREDENTIALING. CONTRACTING Over 500 Contracts Executed in over 25 states. CREDENTIALING Over 3000 credentialing applications completed

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1 CREDENTIALING Practice Velocity has the only full-time team focused on contracting and credentialing for urgent care. This specialized team requests and reviews contracts, performs comparative fee analyses, and negotiates contracts for all PV Billing clients. CONTRACTING Over 500 Contracts Executed in over 25 states n BlueCross/BlueShield n Humana n UnitedHealthcare n Cigna n Great West n Aetna n Corvel n Coventry/First Health ROI: Many final contracts at >10% more than initial offering. CREDENTIALING Over 3000 credentialing applications completed n Rapid Turnaround Time n Let go of Administrative Burden n Automated Software Solution n NCQA Standard Knowledge n Knowledge of State Mandated Applications n Medicare & Medicaid Enrollment Kelly Mattingly Director, Contracting and Credentialing 4 >10 years managed care experience 4 National urgent care contracting expert 4 Familiar with NCQA standards 4 UCAOA CONTRACT MAINTENANCE n Renegotiations n Comparative Fee Analysis n Contract Review for Administrative Language Issues contracts in 28 states 4 3,000+ credentialing applications

2 Practice Velocity s contracting and credentialing team has worked with most major carriers, including: Aetna BCBS Cigna CorVel Coventry National Level DMEPOS First Health Great West Humana/ChoiceCare Medicaid Medicare Multiplan/PHCS/ Beechstreet Tricare United Healthcare REGIONAL Level Access IPA AccessDirect Active Care Plus Advent AHS Network Allegiance of Montana Allied Health Physicians Alta Med Amerigroup Ameriplan Ancillary Care Services Anthem BlueCross Atlantis Avalon AvMed BlueCross Northeast NY BlueCross of NE PA BlueShield of CA Brand New Day Bravo Health Bright Health Physicians CampusCare Capital BCBS CareFirst BCBS Caremore Health Plan Century Health of Kansas Citizen Choice Citrus Valley Cofinity Colorado Access Community Health Choice Community Health Plan Community Health Plan Comprehensive Health Services CompResults Devon Health Devon Health Services Direct Net Duke Select East Texas Health Benefit ECOH Empire BCBS Employers Health Network First Choice of Midwest FMH Benefit Services Galaxy Health Network GEHA Geisinger health Services Gemcare GHI/Emblem Health Golden State Physicians Harvard Pilgrim Health America (a Coventry company) Health EOS Health First Health Plans Health InfoNet Health Net Health Partners of Kansas Health Plus Health Spring Healthcare Partners HealthChoice HealthSmart Heritage Provider Network HFN Highmark BS Hill Physicians HIP Horizon BCBS Horizon Casualty Services Independence BC InforMed Integrated Health Plan Intergroup Intergroup Services Interplan Interwest Health Jai Medical Johns Hopkins EHP Key Risk Keystone Mercy Lehigh Valley Health System MagnaCare MD Physicians Care MedCost Medica Medical Mutual MedRisk Memorial Health Partners Mercy Care Mercy Medical Group Midlands Choice MMSI Molina Health Care MVP Healthcare My Community Care National Care Network New West Health Novanet PPO OGB LA OHARA Optacomp OSU Health Plan Pacific Independent Physicians Physician Healthways Pinnacol PPO Plus Preferred Community Choice Preferred IPA Preferred One Premier Work Comp Prime Care chino Prime Health Services PrimeSource Priority Partner Promesa Health Prospect Medical Group Qual Care Rockport Community Network Rocky Mountain Health Plan Sierra Nevada Medial Group Sloan s Lake Southland San Gabriel Staffcorp Summit Work comp Texan Plus Texas Health Springs Texas True Choice The Alliance Three Rivers Provider Network Trilogy Health Tufts Health Plan TX Children Health Plan U-Care MN Unicare Universal Assistance Universal SmartComp USA MCO Vantage Health Verity Health VIVA health WEA trust Wellcare Wellpath WIN Health WPS private health

3 CREDENTIALING Contracting Timeframe Definition: The process of creating a binding relationship between the insurance company and the group of providers or individual providers. Contracts will outline what each party is responsible for the duration of their relationship such as: payment terms, reimbursement terms, termination terms, etc. The initial phase of the contracting process can take up to 3 months, depending on payor. What happens in this timeframe? Phone calls, pre-application process, market analysis and approval to send out contract and to receive contract. Analyzing reimbursement, reviewing total contract language, negotiating, waiting for return phone calls, finalizing contract, sending contract to provider for signatures. Payor will execute contracts at corporate office, send us a copy, and issue a contract effective date. 1 month 2 months 3 months 4 months 5 months 6 months plus ** Please be aware that the above is a general timeframe based on clients PV Billing has worked with across the United States. Some contracts do take longer to execute depending on the unique needs and policies of each individual payor or managed care organization. Credentialing Timeframes Definition: Credentialing is the process by which either your facility or individual provider s credentials are closely reviewed and verified to ensure meeting educational or quality standards of the respective MCO or payor. Credentialing rep completes an application and submits to payor The application is verified by the MCO or payor requesting the application. The application is checked for errors or missing information and verified via various primary sources. The application is then prepared for a credentialing committee to be reviewed for participation or denial. Waiting for credentialing committee approval: Credentialing committees are typically held one time per month. After the committee approves or denies an applicant, PV Billing will be notified. 1 month 2 months 3 months 4 months 5 months 6 months ** Please be aware that the above is a general timeframe based on clients PV Billing has worked with across the United States. Some credentialing applications are approved in a much shorter timeframe. NCQA, however, (which is an accrediting body for managed care organizations) allows an organization 180 days (or 6 months) to make a credentialing decision.

4 PV Billing - Contracting and Credentialing FAQ What is the difference between contracting and credentialing? Contracting and credentialing are two separate processes. Contracting is a process that results in creating a binding relationship between your providers or medical group and the insurance company. The contract will outline: what you and your group will be responsible for, what the payor is responsible for, payment terms, etc. Credentialing, on the other hand, is a process by which either your facility or provider s credentials are closely verified to ensure that you meet the educational, and/or quality standards of the respective MCO or payor. The two processes are very commonly confused to be one process. In some cases the payor works very efficiently to make sure both processes are taking place simultaneously. Other payors only take care of one process at a time (most commonly contracting before credentialing). Contracting: Why does contracting take so long? After you request a contract from a payor, it can take an average of 60 days to receive the contract from the MCO or payor. After receiving the contract, you may be looking at another days of negotiating, receiving final signatures, wait time for the payor to load the contract into their system, and wait time for payor to execute the contract and issue an effective date. Is it true, some payors refuse to contract? Yes. Some payors have implemented what is called a pre-application process. A committee will review specific details about your medical group to determine if there is a need in their network. Most MCO s will review the following details: geographic location, membership in your area, and the demand for your specialty type. If the MCO or payor decides that there is no need in the network, you will be refused a contract for participation. There is usually a certain period of time that you have to wait in order to apply for re-consideration. How do I know which payors to pursue for my new urgent care? If you have worked in the same area (as your new urgent care start up) previously, chances are you will want to pursue those same payors. PV billing also has other resources to determine which payors hold the most market share in your area. Try to hold out on contracting with every payor or MCO that sends you a contract. For example: It is not necessary to contract with an insurance plan that only has one member in your service area. The idea is that you exchange a discount for patient volume. Does PV Billing negotiate reimbursement rates with payors? Yes. Based upon PV Billing s experience with urgent care contracting, our professionals will negotiate reimbursement rates and other contract language. How will I understand what I am signing? Before you sign any insurance contracts, you should review them with a professional. If you work with PV Billing, your contract specialist will send you a contract summary outlining the important terms of the agreement. We will make sure you are comfortable with your contracts. How will we know when we are officially in-network (or) participating with an insurance network? Consistent follow up is key. If you work with PV Billing, our staff will follow through with the contracting process until a contract is fully executed. When the PV Billing contracting specialist is notified of an official effective date, the client will be the first to know through the following methods: notification, and bi-weekly status reports. Keep in mind: Even if you have a contract in place with an issued effective date, the actual effective date is typically the later of the contract effective date and the credentialing approval date.

5 CREDENTIALING Credentialing: Why does the credentialing process take so long? There are many reasons why the credentialing process could potentially take a long time. A) Most payors are accredited through an agency such as the National Committee for Quality Assurance (NCQA). NCQA allows a health plan 180 days from the time a completed credentialing application is submitted to: verify the components of the application, send the application to a credentialing committee, and notify the provider or facility of the decision to approve or deny the provider or facility into the health network. B) During the early summer months, many physicians are finishing Residency programs. This means the employers that these physicians are newly employed with are initiating in-network status with various health plans. This causes a major back up year after year. C) Some MCO s or payors outsource primary source verification of provider or facility credentialing. The time frames for processing an application will vary depending on the contract between the MCO and the outsource agency (or) credentials verification service (CVS). D) Most health plans or payors have a limited number of credentialing committees per year. This means your credentialing file may be complete and ready for approval, but the credentialing committee meeting may be scheduled more than a month away. When can my clinic and providers be credentialed with a payor? The credentialing process, alone, can take up to 180 days. The clock starts ticking after the payor receives a complete credentialing application. While I am waiting for my provider to become credentialed, can I submit a bill to the insurance company for the provider s services? You can bill for the provider s services, however, until the provider is fully credentialed with the payor, your urgent care should not expect payment. Most insurance companies have different credentialing criteria. For example: BCBS may require credentialing of all practitioners, regardless of whether the provider is a physician or a mid-level. On the other hand, Aetna may not require credentialing of any practitioners. Another payor may require credentialing of the physicians but not of the mid-levels (requiring the mid-level to bill under a supervising physician). It is very important to stay on top of these intricate details. What is the difference between facility credentialing and individual provider credentialing? A facility credentialing application will usually require you to provide specific information about your urgent care practice not the individual providers. Individual provider credentialing will require every provider practicing at your facility to complete a credentialing application. It makes the most sense for urgent care providers to be credentialed as a facility, although the decision is solely up to the MCO or payor. (Continued on next page)

6 How often is a facility or provider re-credentialed? Most MCO s or payors will require re-credentialing every 2-3 years. If my employed practitioners are currently credentialed with insurance plans, will they need to be credentialed again at the new urgent care? The answer to this question depends on the credentialing policies and procedures of the MCO or payor. In most cases, a payor will only require a provider to submit a letter adding a new location and Tax ID to their existing provider s credentialing file. Other payors may ask for you to start the process from ground zero.

7 CREDENTIALING Working with PV Billing: Outsourcing Contracting and Credentialing If you are considering delegating (or you currently do delegate) contracting and credentialing to PV Billing, these FAQ s will assist you while working with us. Applications: Do I need to submit both the facility and provider applications to PV Billing? Yes. These applications will aid in the process of completing credentialing applications for your facility and individual providers. PV Billing is unable to initiate your contract and credentialing requests without completed applications. Also remember to keep an electronic PV Billing provider application on file. Anytime you have a new provider starting in your clinic we will need you to submit a completed application (along with requested documents). We want to make sure your providers are participating as soon as possible. Where can I send the completed applications? Please send the completed applications to the address listed on the PV application. Other acceptable methods of delivery are via fax or . Upon signing a contract with PV Billing, you will be assigned a credentialing specialist. At that time, additional contact information will be given to your group. Attachments: Do I need to submit all of the attachments listed on page 1? Please submit all documents unless they do not apply to your practice or individual providers. For example: Not all states require practitioners to obtain a controlled substance. What is the difference between a provider NPI and a facility NPI? Every provider in your practice needs to apply for an individual NPI. This is a unique identifier that follows your practitioners at your facility and any facility they will practice at in the future. Your facility also needs to apply for a group NPI, also known as the type 2 NPI. This is a unique number that identifies your facility or group. If you still have not applied for a number, please visit the NPI website ( and complete the online application. Most requests are processed in a few days. Hint: when completing your group NPI, make sure the clinic name you submit on the NPI form matches exactly that of the name on your CP575 (IRS form). Will PV accept the confirmation from the enumerator system as a verification letter? Yes. Any confirmation that is directly from NPI will be accepted. How do I know if I have a Medicare number? Some providers may not know if they have a Medicare number because their previous employer may have enrolled on their behalf. There are a few ways to check if you have an existing number. First suggestion: Contact your previous employer and ask for your Medicare number, Second suggestion: Check the ecare website ( com/), Third suggestion: write a letter to Medicare requesting that they verify whether you are enrolled in Medicare for the state you will be practicing. (Continued on next page)

8 Working with PV Billing: Outsourcing Contracting and Credentialing (Continued) What is a CP575? A CP575 is a document that you should have received from the IRS confirming your business tax identification number. Why does PV Billing ask for a quality improvement plan on page 1 of the facility application? Insurance companies are always looking for better ways to improve their provider selection process. They want to ensure the highest quality providers will be taking care of their members. One way of maintaining oversight of quality is to request that medical facilities implement and follow quality standards as well. At this point in time, the quality plan has been recommended and not required. Why does PV need my social security number? Most credentialing applications require a social security number. PV billing will use your social security number only for that purpose. How do I apply for a CLIA certificate? There are forms available on the CMS Medicare website. Please visit CMSForms/CMSForms/list.asp - and search for the CMS116 form. Why does PVB ask for my providers NPI usernames and passwords? We only need the provider s NPI usernames and passwords if PVB will be completing Medicare enrollment on the provider s behalf. PVB completes Medicare enrollment through the PECOS system, which is Medicare s electronic enrollment database. Your credentialing specialist cannot gain entry (login) to the PECOS system without the NPI username and password. In the past PVB would complete enrollment applications via the paper application, but we found that process to be tedious as the applications were hand written and the processing time was much more lengthy. The typical approval timeframe for a PECOS application is 30 days, whereas the typical approval timeframe for a paper application is closer to 4-6 months. Other Information: After I complete and submit the applications, will PV Billing need additional information from my clinic and practitioners? Yes. As various documents expire, PV Billing will request new copies. Examples: Insurance, licensure, board certification, etc. We will also require original signatures on credentialing applications as they are completed. Most payors will not accept electronic signatures. Does PV Billing need to be notified if we decide to change our legal name? Yes. While you are contracted with PV Billing, it is important that we are aware of changes preferably as soon as you are certain the change will occur. Many changes will impact your contracts with insurance plans, and may even affect billing and collections. Please notify us of the following (not all inclusive): 3 Change of your FEIN or tax id 3 Change of legal business name or doing business as name 3 Change of phone or fax number 3 Any change to the information on your PV Billing facility application 3 The addition of a new provider in your facility 3 The closing or addition of a clinic location Is my clinic and provider information confidential? Absolutely. We only use the provider and clinic information to perform contracting and credentialing requests. We do not share information with other third parties. When the contract between PV and the medical group has been fulfilled or terminated, all information will be returned to the medical group or destroyed.

9 CREDENTIALING Cost of Services: What is the cost for contracting and credentialing services? Please request a PV Billing Contracting and Credentialing services agreement. You may Kelly Mattingly at [email protected]. The cost structure is defined in this document. Will we be billed later for services, or do we pay upfront? Contracting services are due prior to initiating any of your contracting requests. Credentialing will be billed at a later date, as credentialing applications are completed. Do you accept credit cards to pay for initial contracting services? Yes. Please contact your contracting specialist to arrange for payment. Why are credentialing services billed at a later date? Credentialing costs are different depending on the type of credentialing the payor or MCO offers. Since we do not always know what type of credentialing your facility will be offered, you will be billed when we do know. PV Billing Case Study

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