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PROVIDER ENROLLMENT SERVICES

Becoming A Medicare Provider

What is Provider Credentialing?

Credentialing is an in-depth review process to verify a healthcare provider’s qualifications to ensure they can provide care or services to patients. The process includes obtaining and assessing documented evidence of a provider’s licensure, education, training, career history, and other qualifications from a primary source (such as a medical school). It also includes submitting applications for data and other processes, like malpractice claims review.

Why is PECOS Required for Medicare Enrollment?

 

There are two ways to enroll in the Medicare program. First, complete the appropriate Medicare paper applications, or second, use the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). PECOS supports the Medicare provider and supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information.

PECOS stands for Provider, Enrollment, Chain, and Ownership System. 

PECOS Pre-Enrollment Checklist

Before you begin registration in the PECOS, make sure you have all of the information CMS requires. The checklist below details all of the information and documents you will need to complete enrollment successfully:

  • National Provider Identifier (NPI)

  • National Plan and Provider Enumeration System (NPPES) ID & Password

  • Personal Identifying Information i.e., Legal name, Date of birth, and Social Security number

  • Schooling Information like School name, and Graduation year

  • Professional License Information i.e., Medical license number, Original effective date, Renewal date, and State issued

  • Certification Information i.e., Certification number, Original effective date, Renewal date, and State issued

  • Specialty/Secondary Specialty Information

  • Drug Enforcement Agency (DEA) Number

  • Electronic Funds Transfer Authorization Agreement CMS-588

  • Information About Final Adverse Actions (if applicable)

  •  Practice Location Information

  •  Medical practice location

  •  Special payment information

  •  Medical record storage information

  •  Billing agency information (if applicable)

  •  Any federal, state, and/or local professional licenses, certifications and/or registrations required for practice

 

PECOS Enrollment

After you log in to the PECOS system, you will be guided through a series of steps to select the appropriate application and enter your information. Similar to selecting the appropriate paper application, it is important to select the proper enrollment type within the PECOS system so that you transfer the appropriate information to Medicare for your enrollment record.

 

After submitting your application via PECOS, you can check the status of your application online directly with the MAC through their website or via the PECOS application status check page. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Ordering-and-Certifying

 

Suggested Links:

For enrollment:  https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index

If you don’t know your NPI: https://nppes.cms.hhs.gov/

Enrollment & Certification Contracts

MEDICAID PROVIDER ENROLLMENT

Requires between 20 to 24 different regulatory compliance-related policies and procedures to be uploaded at the end of the online web application.

CMS promulgated requirements via regulations at 42 CFR:
− 455 Subpart B (Disclosures)
− 455 Subpart E (Screening and Enrollment)
• The federal regulations became effective March 25,
2011 (except FCBC)
• These requirements mirror those implemented in
Medicare—with a few exceptions

MEDICARE PROVIDER ENROLLMENT

​Checklist for Sole Proprietor or Solely Owned Organizations (eg. LLC, PC) Below is a checklist of information that will be needed to complete enrollments via Internet-based PECOS:

An active National Provider Identifier (NPI).

      - Sole Proprietors only need a type 1  NPI

     -  Solely Owned Organizations need both a type 1

    (Individual) NPI and type 2 (Organization) NPI

National Plan and Provider Enumeration System (NPPES) User ID and password. Internet-based PECOS can be accessed with the same User ID and password that a physician or non-physician practitioner uses for NPPES.

 

PRIVATE PAYER/INSURANCE ENROLLMENT

Private insurance usually requires a contract to exist between the provider and the insurance prior to providing care to a patient.  The major private insurance payer include: UHC, Cigna, Humana, BCBS, Aetna, Aetna Better Health, MVP Healthcare, Harvard, Peach State, WellCare, Beacon Health option, Oscar, Molina Healthcare, Oxford, UMR, AARP, Multi plan, Freedom Health, AmeriHealth, Amerigroup, Emblem Health/GHI, Health Net, Magellan, Veterans Affairs (VA), Kaiser Permanente, Meritain, WellMed Medical Management, Inc, Tricare East/West, Tricare for Life, Fidelis care, MVP, GEHA, Tufts Health Plan, First Health network, QualCare Inc, Progressive, Mutual of Omaha, HHP, Capital Health Plan (CHP)

ACHC ACCREDITATION

Get a handle on accreditation. Don’t take chances with medical accreditation! Budgets are determined by accreditation levels, and you don’t want to miss out on your full benefit from your accrediting body.

THE JOINT COMMISSION ACCREDITATION

Let Others Know You Stand for Quality Care. While there are certainly other accrediting bodies, choosing The Joint Commission means you can lean on our 70 years of experience — from our humble beginnings to the worldwide symbol of quality improvement we’ve grown to be

Payor Enrollment vs. Credentialing

While medical credentialing is an essential process to certify a provider’s qualifications, payor enrollment is the process of requesting participation in a health insurance network as a medical provider. This can include major commercial payors such as UnitedHealthcare, BlueCross BlueShield, Humana and Aetna, for example, regional insurance networks, or government public programs such as Medicaid and Medicare. 

Many practices consider payor enrollment a crucial first step in the revenue cycle. As healthcare costs have surged over the years, patients have experienced a nearly 30% increase in deductible and out-of-pocket maximum costs. That has led to fewer patients choosing to see providers who are out-of-network, refusing to cough up higher copays. Instead, patients choose providers who are in-network and covered by their insurance. 

It is strongly advised that providers do not see patients before the completion of this step as reimbursement is not retroactive and doing so could lead to lost revenue.  

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347-443-9636

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Our credentialing services include:

  • Provider enrollment services for physicians and healthcare entities (credentialing and contracting with health plan

  • We guide your practice administrators and providers in gathering the required demographics and background information.

  • We submit the CAQH (Council for Affordable Quality Healthcare) application for providers who must use this service to credential with individual payers.

  • Once we have all the required documentation, we prepare and submit the required applications to the payer organizations.

  • We manage all-payer communications, verifications, and follow-up activity and tasks.

  • We work with you to ensure credentials are up-to-date year after year.

  • Medicare provider enrollment and re-validation services

  • Credentials verification for physicians and ancillary healthcare providers

  • Network management for health plans

  • Managed care contracting

  • Healthcare administration consulting services

  • Our staff will work with any insurance companies to get your practice providers enrolled with health plans and to maintain your providers credentialing files.

Benefits Of Our Program:

  • Keep all your credentialing information in one place.

  • Years of experience to navigate through the process of Medicare and Medicaid provider enrollment, Commercial Insurance Provider Enrollment, and other healthcare provider credentialing needs.

  • Status reports keep you up to date on the progress of your credentialing

  • You and your medical office staff can focus on more important patient matters than dealing with enrollment paperwork

  • Data entry of paper applications

  • Ongoing monitoring services

  • Application mailing service

 

Features Of Our Program:

  • We make all the calls, follow-ups, & submit all applications, e-mails & faxes for you!

  • Dedicated Account Manager

  • 24/7/365 Availability

  • Provider Portal and Practice Manager Portal

  • Automated Alerts & Renewals

  • Secure Document Storage

  • Compliance Reports & Dashboard

  • Pay as you go model – no long term contracts – cancel anytime