Credentialing for Billing A Team Effort

1. Credentialing for Billing A Team Effort Rima Handal UCSD Medical Group, Business Services Phone: 619-543-1899 Fax: 619-543-3183

2. Overview • Credentialing • Credentialing for Hospital Privileges • Credentialing for Billing Privileges • How do Medical Staff Administration and UCSD Medical Group work together “Work Smarter not Harder” • The Role of Business Services, Provider Relations • Obtaining & Establishing Billing Privileges for Physicians and Non-Physician Practitioners • The Provider Billing Packet • The Role of the Department, Divisions, & Academic Staff • Contact Information • Questions and Answers

3. What is credentialing and Why • Credentialing is an extensive Background check from primary sources, plus a peer review process • Credentialing for Hospital Privileges • Assure only qualified, competent practitioners are providing patient care at the Medical Center • Protect the patient, the Medical Center, physicians, & Practitioners • Credentialing for Billing Privileges • Assure only qualified, competent practitioners are providing patient care to Contracted Health Plan members • Protect the patient, the Medical Center, physicians, Non-Physician Practitioners, and Contracted Health Plans • Health Plans ensure only qualified practitioners’ Services are covered and Reimbursed

4. Credentialing Whose rules do we follow For Hospital Privileges TJC (Joint Commission) standards State of California – DHS regulations UCSD Medical Center Medical Staff Bylaws, Rules and Regulations For Billing National Committee on Quality Assurance (NCQA) standards or; American Accreditation Healthcare Commission (URAC) standards Individual Health plan Requirements

5. THE CHALLENGE • Coordinate seemingly different goals • Assure qualification and competence • Generate Revenue • Care for patients • Comply concurrently with sometimes conflicting standards and regulations of multiple agencies

6. So Many different standards! How we make it workThe UCSD Way “Work Smarter not Harder” UCSD Medical Staff Administration and UCSD Medical Group Joined resources & efforts Identify similarities and differences between TJC, NCQA, URAC, and Health Plan Requirements (use strictest standard) during the credentialing process Develop and revise Policies & Procedures and Bylaws to reflect changes in standards and regulations Enroll only practitioners with active UCSD Clinical Privileges with Health Plans

7. What is the SignificanceThe UCSD Way “Work smarter not Harder” • NCQA-Delegation of Credentialing for Billing Rule: • Health Plans May delegate the credentialing function to another entity (UCSD), while maintaining oversight of the function through annual audits • Does not apply to Government plans (i.e. Medicare, Medi-Cal, CCS, GHPP) do not delegate the Credentialing Function.

8. Delegation of Credentialing The UCSD smart Way “Work smarter not Harder” • What is delegation of credentialing?? • Health Plans assign the credentialing function to UCSD • Health Plan maintains oversight of credentialing function • Health Plans conduct Annual audits • NCQA conducts occasional audits to ensure Health Plan oversight

9. Why Delegation of Credentialing The UCSD Way “Work smarter not Harder” • Why strive for delegation of Credentialing? • UCSD already performs the Credentialing • Less Health Plan enrollment applications to complete and submit • Faster addition of new practitioners (Financial impact) • Patient Satisfaction

10. Why make it work!The UCSD Way “Work smarter not Harder” • In terms of billing, credentialing makes the most difference in the insurance arena: • Financial Impact • All Health Plans including government plans are required to credential each practitioner before enrolling him/her as an In- network provider. • Each Plan assigns approved practitioners a billing number • The specific provider billing number is required on the claim for reimbursement • Patient Impact • Practitioners may not render services to Health Plan members until they are fully credentialed and approved by the contracted Health Plan

11. The Role of Business Services, Provider Relations Credentialing for Billing Enrollment of providers with Health Plans Compliance Establishing and Maintaining provider numbers in GE IDX Billing System Representing Providers with Health Plans Representing UCSD during audits Liaison with UCSD Managed Care and Medical Staff Administration

12. The New Provider Billing Packet • New Billable Provider - Billing Packet: • Available by Hard Copy or electronically by e-mail • Includes two Sections/Folders: • Provider Section/Folder (Files are numbered in the order that will make the completion easy) – It includes: • Detailed Instructions Sheet • Check List of all required attachment • Internal UCSD Enrollment Application • Specific Pages that include legal questions for provider response • Application Signature page for Medicare, MediCal, CCS and Emergency Fund specific Applications • Department Section: • Detailed Instructions Sheet for the Department • Department Form, includes Financial & Clinic information

13. The New Provider Billing Packet • Provider Section/Folder (Files numbered in the order that will make it easy to follow the instructions Sheet: • 0 – PRINT – READ BEFORE YOU START (Instructions) • 1 – Provider Section A – Required Attachments & Provider Profile • 2 – Provider Section B – Compliance Training Memo • 3 – Provider Section C – Internal Agreements • 4 – Provider Section D – CMS855I (Pages 7,8,13 and 26) • 5 – Provider Section E – CMS855R (Signature Page 5) • 6 – Provider Section F – DHCS 6216 rev 2-08 – DHCS Medi-Cal • 7 – Provider Section G – DHCS 4514 – CCS Paneling • 8 – Provider Section H – Physicians Emergency Fund • For Reference Only: • 97 – Provider Section I – For reference only, The complete CMS855I • 98 – Provider Section J – For reference only–The complete CMS855R • 99 – Sample of official NPI letter

14. The New Provider Billing Packet Provider Section Folder and Files Review

15. The New Provider Billing Packet • Department Section Folder: • 1 – Instructions Sheet • 2 – Department Form • 3 – Sample of Official NPI Letter

16. The New Provider Billing Packet Department Section Folder/Files Review Profile Roster

17. Billing Compliance • All providers must attend UCSD Online Compliance training prior to any charges being released • Teaching Institutions Guidelines • Billing for Fellows in ACGME programs • Billing for Fellows who are not in ACGME programs • Billing for providers under certain Visa’s

18. Establishing Billing Privileges • Provider Relations receives the completed billing packet • Validate completeness • Contact department contact for any missing items • Validate Hospital Privileges • Validate that provider completed the UCSD online compliance training • Provider information entered into Access Database • Database used to generate completed Applications that will be submitted on behalf of the provider to Government plans • Using Database, print and submit Provider Profile to Contracted Delegated Health Plans

19. Establishing Billing Privileges • All billable providers are established in GE IDX and Managed Care Systems to facilitate: • Building Provider Templates • Scheduling of patient Visits • Access to Epic • Posting charges for rendered services • Generating claims to bill insurance or patients • Posting payments • Reporting charges and collections to Divisions/Departments • Transfer of collections to Division/Department

20. GE IDX Dictionaries • Part listing of GE IDX Dictionaries: • Division Dictionary (102) • Billing Area Dictionary (202) • Provider Dictionary (3) • Scheduling Department Dictionary (301) • Scheduling Provider Dictionary (302) • Referring Provider Dictionary (123) • Managed Care Vendor Dictionary (471 and 686) • Financial Class Dictionary/Patient Health Plan (19) • Payment Code Dictionary (2)

21. Some of the fields in the Provider Dictionary 3 Name: (Provider’s Name) Division (School of Medicine Department) Billing Area: (Combination of Specialty, and how financial data reported back to the Department) Individual Blue Shield: Provider number to be reported on claims when billing Blue Shield claim Blue Shield Billing Code: UCSD Group number, to be reported on Claim to ID provider under UCSD Contract Individual Medicaid ID Specific Provider billing number assigned by Medi-Cal as a result of application process Medicaid Group Number: UCSD Group number assigned by Medi-Cal, required for Medi-Cal payment Individual Medicare ID: Specific Provider billing number assigned by Medi-Cal as a result of application process Medicare Billing Code: UCSD Group number assigned by Medicare, required for Medicare payment State License #: Provider California License number Champus Billing Code: Required to generate Champus Tricare Claims Fund: A = Full Time Faculty B= Non Salaried Volunteer Faculty (Clinical Appointment required) Corresponding Hospital PID: Required to connect all systems electronically GHPP Billing Code: Required to generate CCS and GHPP claims Railroad Medicare: Individual provider number assigned to the provider required to bill claims NPI Number: Individual National Provider Identifier Issued by NPPES replaced previously used UPIN. Required identifier on all HIPAA transactions HIS Primary Service: Required to connect Visits and apply charges to correct providers CMS Individual Vendor: Individual Provider number assigned by CMS required for billing CMS CMS Master Group Vendor: UCSD CMS group number required for billing CMS Attended Compliance: Field should be valued as Yes for any charges and claims to be generated Caloptima ID#: Individual Provider number assigned by Caloptima, required for claim payment Employee ID #: Required for Reporting Group NPI # UCSD Department NPI number

22. Billing for Non Physician Practitioners • Items to Consider: • Health Plan rules and Regulations • Government Guidelines • Employer (Medical Center vs. Department) • Department authorization for billing Non Physician Practitioner Services • Two types of Billing of Non-Physician Practitioner Services: • Independent Billing • Incident-to Billing

23. Billing Integrity • Built-in Electronic edits and specific claims logic for • Missing provider numbers by plan • Missing critical provider information by health plan. • Claim missing required numbers will not be billed and no claims will be generated until numbers are updated • online compliance is not completed • No claims will be submitted for providers who are not crednetialed and approved by Medical Staff Administration

24. The Role of the Department, Division and Academic Staff • Submit Applications timely: • It takes Medicare about 3-4 months to assign provider billing numbers • It takes Medi-Cal about 6 months to assign provider billing numbers • Retro-active status is not granted – Financial impact • Timeliness for filing claims (Financial impact) • Submit Complete applications and attachments: • Submit complete, accurate applications • Ensure all required attachments are included • Ensure all attachments are legible and valid • Check for Signatures • Communicate any changes to Provider relations

25. Contacts • UCSD Medical Group, Busienss Services • Provider Relations Unit • Rima Handal, Operations Manager • Phone: 619-543-1899 • Fax: 619-543-3183 • Email: rhandal@ucsd.edu • Odette Maria: Provider Enrollment Coordinator • Phone: 619-543-1891 • Fax: 619-543-3183 • Email: omaria@ucsd.edu

26. Questions and Answers

27. Click to Edit Closing Statement