Question: What is Medical Credentialing?

Answer: Medical Credentialing is the process of submitting your application to an insurance carrier, to participate with them as a new provider. Question: Why would I want to go through the process of becoming credentialed with different insurance companies? Answer: Because if you are participating with different insurance carriers, you will be able to increase you patient list and your income, due to the fact that most patients only go where their insurance is accepted! Question: What process will I have to go through to become credentialed? Answer: You will need to fill out a lengthy application (which can vary with each insurance carrier) with information such as; schooling, licensing, experience, liability insurance coverage, languages spoken, etc on the application.

Not sure what forms you might need to have filled out? Here's how to tell what you need.

* A solo provider practicing by himself (or herself) will need an 855I and, an EFT (electronic funds transfer) form and a 460 Participating Provider Agreement. * A group of providers practicing together under one name and tax ID# will need an 855B and 855I's (for each individual provider), an EFT, 855Rs and a CMS 460.

What is credentialing? Healthcare organizations such as health plans and hospitals evaluate physicians and other health care providers and other healthcare providers with whom they contract to confirm that these providers are adequately trained, certified and/or licensed to provide care. One of the most integral parts of the credentialing process is the collection and verification of vital data regarding the healthcare provider's education, training, experience, practice history, location, disclosure of any issues impacting their ability to provide care, and other background information. Three steps are involved in completing the credentialing process: Collecting self-reported data from providers (education, training, location, etc.); Verifying certain provider-reported data against third-party sources (Primary Source Verification); Reviewing the data in order to make an independent decision about whether the provider in question meets that organization's standards for participation.

The CAQH Universal Provider Datasource offers an administrative simplification solution to the first step of this credentialing process, the application data collection. Health plans, hospitals and other healthcare organizations will continue to make their own, independent decisions with respect to each provider's application for participation or privileges. | TOP | Why is administrative simplification for credentialing an important issue? A time-consuming task facing physicians and other health care providers and healthcare organizations is the paperwork associated with credentialing. A typical healthcare provider contracts with 10 to 20 healthcare organizations, each of which requires the provider to complete an extensive credentialing application. The CAQH Universal Provider Datasource will simplify the process by enabling providers to submit one standard credentialing application to one source, the CAQH credentialing application database, to satisfy the credentialing requirements of the health plans participating in the initiative. This will significantly reduce the administrative requirements now associated with the credentialing application process. | TOP | How was the standard application created? CAQH member health plans reviewed more than 40 different credentialing applications including health plan applications, standard applications adopted for use in different states on a voluntary or mandated basis, and other uniform applications used in the industry. CAQH developed and adopted a standard credentialing application data set intended to meet the needs of most health plans. The standard application includes a broad range of data used in the credentialing review process, other key practice data for use in directories, a standard set of disclosure questions, an authorization and a release statement. CAQH sought feedback on the application from national accrediting bodies, physician organizations and other interest groups. | TOP | Who is developing the CAQH database? After an extensive search, CAQH selected GeoAccess, a healthcare-focused technology and data management company, to build and administer the credentialing data system. GeoAccess was selected because of its well-established expertise in developing and managing highlyscalable, secure systems for acquiring and storing confidential provider data for hundreds of clients throughout the healthcare industry. The company is one of the nation's largest independent credentialing solutions vendors and has a very robust and accurate national database of healthcare providers. | TOP | How will the confidentiality and security of provider information be ensured? The confidentiality and security of provider information and the privacy of system users are critical priorities for CAQH. The CAQH Universal Provider Datasource is designed to be compliant with laws, rules and regulations relating to the privacy of individually identifiable health information. In addition, CAQH will comply with applicable laws and regulations pertaining to confidentiality and security in the development of the database and the data collection process.

The CAQH database is housed in a secure Network Operations Center, which is controlled by biometric hand scanners, and access is limited to engineers and monitoring staff. All network traffic to and from the center is routed through redundant firewalls for complete security to the database and online systems. Secure Internet accesses to application screens, use of passwords, electronic signatures/certificates, and powerful 128-bit Secure Socket Layer (SSL) encryption are used to ensure only authenticated use of the system. Only password/PINauthenticated users have access to their restricted data over connections that automatically encode all information exchanges. Virus detection mechanisms are used to ensure that the database and the Websites are free of all viruses. Routine tape back-ups protect all volatile system data and are secured in an off-site storage facility. | TOP | When will the Universal Provider Datasource be available and what are the timelines? The CAQH Universal Provider Datasource was launched in Virginia and Colorado in March 2002. A nationwide roll-out began on a month-by-month schedule in June 2002 and will continue through 2003. | TOP | Who will be able to access the credentialing database? For the initial roll-out phase in each state, all health plans in the state will be invited to participate. Other healthcare organizations to which participating health plans delegate the credentialing functions may also choose to participate in the database initiative. Following implementation and an initial period of maintenance with the health plans, hospitals will be invited to join in the initiative. In all cases, CAQH will only release a provider's information to a health plan or other healthcare organization with the provider's authorization. | TOP | Who is paying for the database and how much does it cost? There is no cost for physicians and other health care providers to use the credentialing application database. The costs associated with the design and development of the database and data collection process have been funded by CAQH through membership fees. Health plans and other healthcare organizations participating in the initiative will pay a set administrative fee and set fee per provider to access the database. To access the database, interested organizations should contact CAQH for more information about pricing. | TOP | Where can I get additional information on this project? For more information, visit the CAQH Website at www.CAQH.org or call (202) 861-1492. | TOP | Why would I use the "CC E-mail" fields? If you have personnel who assist you with your credentialing documentation requirements, you may want to enter their e-mail addresses in the "CC E-mail" fields so that they will be copied on any credentialing related e-mail messages that are sent to you. | TOP |

Among Physicians (and Other Healthcare Providers) What is the objective of the CAQH Physician Provider Datasource? The CAQH Provider Datasource is designed to accomplish administrative simplification by gathering credentialing data in a single repository that may be accessed by participating health plans and other healthcare organizations. Its objective is to simplify the credentialing data gathering process and enable physicians and other health care providers to easily update their information. | TOP | Why is the CAQH Provider Datasource important to me? Healthcare organizations such as health plans and hospitals evaluate physicians and other health care providers and other healthcare providers with whom they contract to confirm that the healthcare providers under contract are adequately trained, certified and/or licensed to provide care. One of the most integral parts of the credentialing process is the collection and verification of vital data from the physician regarding his or her education, training, experience, practice history, location, disclosure of any issues impacting their ability to provide care and other background information. Credentialing involves a tremendous amount of paperwork and administrative time. The CAQH Provider Datasource will greatly reduce the amount of administrative time required in this process for physicians and other health care providers. | TOP | How can I access this database? Access and registration instructions will be sent to physicians and other healthcare providers as the initiative is launched in your market. You can use your personal ID and password to directly access the database over the Internet. You can transmit the completed application electronically through your modem, or you may call to request an application be sent by mail. All you need to do is complete this paper copy and fax it back to a toll-free number. | TOP | How will my confidentiality be maintained within the database? The confidentiality and security of provider information and the privacy of the system users are critical priorities for CAQH. The CAQH Universal Provider Datasource is designed to be compliant with all laws, rules and regulations relating to the privacy of individually identifiable health information. In addition, CAQH will comply with applicable laws and regulations pertaining to confidentiality and security in the development of the database and the data collection process.

The CAQH database is housed in a secure Network Operations Center that is controlled by biometric hand scanners. It is limited to engineers and monitoring staff. All network traffic to and

from the center is routed through redundant firewalls for complete security to the database and online systems. Secure Internet accesses to application screens, use of passwords, electronic signatures/certificates, and powerful 128-bit Secure Socket Layer (SSL) encryption are used to ensure only authenticated use of the system. Only password/PIN-authenticated users have access to their restricted data over connections that automatically encode all information exchanges. Virus detection mechanisms are used to ensure that the database and the Websites are free of all viruses. Routine tape back-ups protect all volatile system data and are secured in an off-site storage facility. | TOP | Who will pay for the cost to use the database? There is no cost for physicians and other health care providers to use the credentialing application database. The costs associated with the design and development of the database and data collection process have been funded by CAQH through membership fees. Health plans and other healthcare organizations participating in the initiative will pay administrative fees and an annual fee per provider to access the database. To access the database, interested organizations should contact CAQH for more information about pricing. | TOP | How often must my information be updated? You will be sent automatic reminders to review and attest to the accuracy of your data. You must review and authorize data once every four months. This is easily accomplished through a quick online visit or by calling the CAQH Helpdesk at (888) 599-1771. You can make changes to your record anytime by requesting a change form by phone or by directly accessing your information online. | TOP | Why do I need to review and attest to my information three times a year? Because many health plans with which you do business will be using this system for recredentialing and ongoing updating of provider directory records, it is important that the database contains the most accurate and up-to-date information. This may be quickly done via online access. By checking and attesting to your data three times a year, participating health plans can access current information from the database at the time of recredentialing or database updates, without having to contact you repeatedly. This will help you continue to conform to the requirements of each participating health plan with which you contract. | TOP | Can I use the CAQH database to report any changes to my practice such as address, phone numbers, and new associates? The notice section of your agreement with each of the participating health plans typically requires you to communicate certain changes to your personal information immediately. Rather than contact each of these plans individually, you can enter your changes once into the CAQH database for all authorized participating plans to access. Please be aware, however, that only plans that participate in the CAQH Provider Datasource and that have been authorized by you to access your information will receive any changes. You will still need to contact any nonparticipating plans directly. | TOP |

Can any health plan access my data? No. You control which plans have access to your application information. When completing the application, you will indicate which participating health plans and healthcare organizations will be authorized to access your application data. | TOP | What if I participate in a health plan that is not participating in the CAQH Universal Provider Datasource? If you are contracted with a health plan that is not participating in the CAQH Universal Provider Datasource, you will need to continue to deal with that organization directly, separate from the CAQH database process. Healthcare organizations and health plans are invited to participate in the CAQH Provider Datasource, regardless of whether they are members of CAQH. If one of the health plans with which you work is not currently participating in the initiative, please ask them to visit the CAQH Website at www.CAQH.org or call (202) 861-1492. | TOP | How do I input my data if I do not have Internet access? If you do not have Internet access, you can call the CAQH Helpdesk at 888-599-1771 and request an application be sent by mail. All you need to do is complete this paper copy and fax it back to a toll-free number. | TOP | Do I need to complete the entire application? Yes, you are expected to complete all questions on the application. The electronic application will present the questions to you in an interview style approach, with logic that presents the questions that are relevant to your particular specialty or provider type. The system is designed to allow you to complete the application over time. You can stop any time, save what you have completed and return later to finish the process. The entire application must be completed prior to your verification of its accuracy, and before the participating health plans that you have authorized can access it. | TOP | Why does the CAQH application ask for such practice specific details? CAQH is collecting additional information about your practice so that participating health plans can improve and maintain the data in their provider directories and provider data systems, as well as have the full scope of information needed to conduct initial credentialing and recredentialing. Health plans often collect practice information on the credentialing application to have data available to assist health plan members in making more informed selections of providers and potentially reduce the volume of calls to your office for this practice-specific information. As with all of the other questions in the application, it is important that you complete the sections on your practice, and attest to the accuracy of your responses. The CAQH application contains a broad scope of questions so that all of the participating plans can obtain the information that they require for their own credentialing processes without having to contact you directly. With the CAQH Provider Datasource, you only have to complete

the application once, rather than multiple times for each participating health plan with which you do business. | TOP | Who do I contact for administrative support questions when utilizing the database? The CAQH Helpdesk provides a telephone service Monday through Thursday, from 7:00 a.m. to 9:00 p.m. (EST) and Friday, from 7:00 a.m. to 7:00 p.m. (EST) to provide assistance with any questions you may have. | TOP |

Among Interest Groups What is the objective of the CAQH Provider Datasource? The CAQH Provider Datasource is designed to gather credentialing data in a single repository that may be accessed by participating health plans and other healthcare organizations. Its objective is to simplify the credentialing data gathering process and enable physicians and other health care providers to easily update their information. | TOP | Does the CAQH application take into account the accreditation requirements set by groups such as NCQA, JCAHO and URAC? Yes. CAQH designed this system with input from NCQA, JCAHO, URAC as well as many health plans and other organizations. This is a collaborative effort that is intended to help improve the credentialing process for everybody. | TOP | Does the CAQH Provider Datasource include Primary Source Verification of the elements on the CAQH application form? No. Currently, the CAQH Credentialing Source addresses only the data collection part of the credentialing process. Under this phase of the CAQH initiative, health plans and other related organizations will independently perform primary source verification on certain data that is collected, as well as make their own decisions about whether a provider meets that organization's standards for participation. CAQH may, as part of a later phase of activity, pursue relationships with credentialing verification organizations to streamline the primary source verification steps of the process for participating health plans. | TOP | Is the CAQH Provider Datasource applicable in states where there is a state-mandated application? Yes, in states where legislation has passed mandating the use of a standard credentialing application form, the data collected through the CAQH Universal Provider Datasource and data collection process will include the data elements and/or form as is required by the state. The system will automatically ask the provider the necessary questions to fulfill the requirements for the state in which the provider's primary office address is located. | TOP |

Who is building and maintaining the data system? After an extensive search, CAQH selected GeoAccess, a healthcare-focused technology and data management company, to build and administer the credentialing data system. GeoAccess was selected because of its well-established expertise in developing and maintaining highlyscalable, secure systems for acquiring and storing confidential provider data for hundreds of clients throughout the healthcare industry. The company is one of the nation's largest independent credentialing solutions vendor and has a very robust and accurate national database of healthcare providers. | TOP |

Among Health Plans What is the objective of the CAQH Provider Datasource? The CAQH Provider Datasource is designed to gather credentialing data in a single repository that may be accessed by health plans and other healthcare organizations. Its objective is to simplify the credentialing data gathering process and enable physicians and other health care providers to easily update their information. | TOP | Which departments within a health plan will be affected by the CAQH Provider Datasource? Any department of a health plan or related organization that requires current information on its associated providers can benefit from the CAQH Provider Datasource. Typically, for most health plans, the CAQH Provider Datasource will help reduce the amount of paperwork providers need to complete for participating health plans to maintain their processes associated with Credentialing, Provider Relations, Claims and Provider Directories. | TOP | Will participating health plans be able to request additional information outside of the information gathered on the application? The primary goal of the CAQH Provider Datasource is to simplify the administrative process with a streamlined robust data system. Plans should not need to request additional information. The CAQH credentialing data set is very complete. The plans participating in the credentialing data initiative are asked not to seek additional information beyond what is in the CAQH Provider Datasource application on a routine basis. However, health plans may need to clarify or confirm certain responses in the application with individual physicians and other health care providers on a case-by-case basis. | TOP | When will the CAQH provider database be available in my state? The Provider Datasource was launched in Virginia and Colorado in March 2002. A nationwide roll-out will began on a month-by-month schedule in June 2002 and will continue through 2003. | TOP |

Will my health plan be required to utilize the database? No health plan is required to use the database. The CAQH Credentialing Source is completely voluntary. All health plans will be invited to participate. | TOP | Who do I contact for administrative support questions when utilizing the database? Each participating health plan will have an administrator specially trained by GeoAccess to help staff. In addition, there will be on-line training support. The plan's administrator designated for the CAQH database will coordinate any questions you many have. | TOP | My health plan operates in a state with a mandated credentialing application form and/or process. Will we be required to use the CAQH application and database? In states where legislation has passed mandating the use of a standard credentialing application form, the data collected through the CAQH credentialing database and data collection process will include the data elements and/or form as is required by the state. The system will automatically ask the provider the necessary questions to fulfill the requirements for the state in which the provider's primary office address is located. | TOP | If my health plan uses a CVO for primary source verification, will the CVO be allowed to access the database on behalf of my health plan? If a participating health plan utilizes a credentials verification organization (CVO) to perform primary source verification, the CVO will not be able to access the database directly. The participating health plan will access the database to retrieve the application information and may share the relevant data elements with the CVO as needed to conduct the primary source verification services. | TOP | Will my health plan be required to join CAQH in order to participate? No, all health plans are invited to participate in the CAQH Provider Datasource, regardless of whether they are members of CAQH or not. Please visit the CAQH Website at www.CAQH.org or call (202) 861-1492 for more information. | TOP | How much will it cost to join CAQH and to access the CAQH provider database? Health plans and other healthcare organizations participating in the initiative will pay administrative fees and an annual fee per provider to access the database. To access the database, interested organizations should contact CAQH at (202) 861-1492. | TOP | Who can I contact to gain access to the database? Please contact CAQH at (202) 861-1492 if you are interested in participating in the CAQH Universal Provider Datasource. | TOP | Will Primary Source Verification be included as part of the CAQH Universal Provider Datasource?

Currently, the CAQH Universal Provider Datasource addresses only the data collection part of the credentialing process. Under this phase of the CAQH initiative, participating health plans and other related organizations will independently perform primary source verification on certain data that is collected, as well as make their own decisions about whether a provider meets that organization's standards for participation. CAQH may, as part of a later phase of activity, pursue relationships with credentialing verification organizations to streamline the primary source verification steps of the process for participating health plans. | TOP |

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Determine what insurance panel Retrieve uptodate provider application from each insurance company Fill-out forms Get caqh no. and caqh online profile Submit supplementary documentation to insurance company Confirm materials if received Follow-up Submit appeal if there are rejections

Title: Credentialing and Data Specialist

Department: Network

Description: This positions main function is to credential and re-credential behavioral health providers in Beacons network spanning multiple states and regions. The position will perform specified assignments relating to ensuring that processes and protocols are in place to ensure all credentialing file accuracy according to contractual and NCQA standards.

Responsibilities:

Credentials and re-credentials behavioral health providers using Beacons proprietary FlexCare system; Organizes and maintains credentialing files; Works with Network Operations and other Beacon staff to ensure follow up with providers when applications are incomplete Performs Primary Source Verification for individual credentialing & confirmation of facility accreditation and licensure Maintains credentialing management documents Tracking of all credentialed providers for the purpose of re credentialing Accurately enter information into Beacons system of record Monitor and participate in site visit and provider scores Knowledge of NCQA credentialing and re credentialing standards Assists with the revisions and/or development of policies and procedures Prepares files for at least a quarterly Credentialing Committee; Assists with the coordination of Credentialing Committee Participates in evening Credentialing Committee meeting on a monthly basis Record minutes from Credentialing Committee Supports special projects as needed. Other Duties as assigned.

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