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A peek behind the curtain at provider enrollment

Posted by AllWays Health Partners Blog Team on June 03, 2021

Do you know a provider that's interested in switching to AllWays Health Partners? No matter their level of interest, it's good to see how a new provider can turn their interest into a contract. To learn more, we talked with Melissa Hinckley and Charles Murphy of our Provider Network team to break down each step to give providers more sightline into the entire process.

Phase 1—enrollment submission

When a provider wants to join our network, the first step is to submit a Letter of Intent (LOI). Then the provider has the opportunity to discuss joining the network with our Network Growth team. Next, the provider fills out the HCAS application or provider datasheet, which gets passed on to the Provider Network Operations team. At AllWays Health Partners, this is when a provider's CAQH profile is set up with demographic information. This creates a record within our database that feeds into our directory. There are several pieces of data included that go beyond name and address, such as National Provider Identifier (NPI) and specialty. It's also important to know whether the provider is a primary care doctor or not—as this information affects our members. For example, because primary care benefits are often lower cost than a specialty care benefit, this impacts the member experience. This process can take anywhere from 1-45 days—as long as the provider's information is complete and updated. Most often, this is completed much faster than 45 days. After accumulating all of this material, our provider enrollment team must determine if this provider requires credentialing. More often than not, providers will enter the credentialing phase next.

Phase 2—credentialing

Credentialing is the process by which provider enrollment sends out a request to collect information about a provider to ensure that they meet quality standards before joining our network. In other words, credentialing ensures the safety of our members and the quality of care they receive.

If the provider does not require credentialing, they undergo a verification process to validate their licensure and additional authentications.

If the provider does require credentialing, we transfer the provider's submission to our credentialing delegation partner, also known as a credentialing verification organization (CVO). This process can take anywhere from 10-30 days to complete. During this process, the providers' experience and background are validated thoroughly by following all NCQA credentialing guidelines. Some of the information confirmed during the credentialing process includes the following questions:

  • Has the provider's license been verified?
  • Is this provider board-certified? (different for each specialty)
  • Have we validated the provider's medical schooling and training?
  • Has this provider ever experienced malpractice?
  • Does this provider have appropriate levels of malpractice insurance?
  • Has the federal government sanctioned this provider?
  • Where is the provider practicing?
  • Are there any red flags on the building owner's record of where this provider practices?

From here, the provider either gets accepted into our network or rejected from our network.

If the provider is accepted, the provider goes through a provider enrollment quality check to finalize for QXNT, also known as claims readiness.

Phase 3—effective enrollment date

Upon final verification, we issue a contract and effective date confirming when the provider is enabled within our directory as claims ready—and members now have access to the provider's care. Once the new provider is pushed through our system with an effective date, a notice goes to Provider Relations to ensure that the provider is aware of their effective date and is now eligible to see members. The effective date can never be before the "Credentialing Committee" date. AllWays Health Partners ensures that the business line updates the correct Provider Directory, PCP, and PCP Panel Status flags.

It's important to note that providers accepted into our network are also re-credentialed every two years to maintain NCQA standards.

From our perspective at AllWays Health Partners, accepting a new provider is exciting as it benefits our members. Another healthcare professional in our system is another person that can deliver the best possible care to our members.

To learn more, submit a letter of interest.

Topics: Providers, Benefits

Disclaimer: The content in this blog post represents the clinical opinions of the providers at AllWays Health Partners and is based on the most currently available clinical and governmental guidance.

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