Provider Enrollment and Payer Credentialing Processes Flashcards

When a provider is terminated from a payer's network involuntarily, what action is typically required under most state laws and accreditation standards?

Answer: Written notice to the provider with information about appeal rights

Most state laws and accreditation standards require payers to provide written notice to providers of involuntary termination, including the reason and information about the appeals or reconsideration process.

What is the significance of a 'participating provider agreement' being non-assignable?

Answer: The contract rights and obligations cannot be transferred to another provider or entity without payer consent

A non-assignable clause means the provider cannot transfer their contractual rights and obligations to another party (e.g., through a practice sale) without obtaining the payer's prior written consent.

A credentialing committee is reviewing a practitioner with two malpractice settlements in the past five years. What is the recommended approach?

Answer: Conduct an individualized review of the circumstances, amounts, and patterns before making a determination

Accreditation standards require an individualized review of malpractice history, including the nature of the cases, settlement amounts, and whether a pattern of care issues exists, rather than automatic approval or denial.

Which Medicaid enrollment pathway allows providers to streamline enrollment across multiple states using a single application process?

Answer: Inter-State Medicaid Enrollment Compact

The Interstate Medicaid Enrollment Compact (where adopted) allows providers to use a streamlined process to enroll in multiple participating state Medicaid programs simultaneously.

A provider's enrollment application with a commercial payer is denied due to 'credentialing criteria not met.' What is the provider's best first step?

Answer: Request the specific criteria that were not met and the payer's formal appeal or reconsideration process

The first step is to understand exactly which criteria were not met by requesting clarification from the payer, then following the formal appeal or reconsideration process outlined in the provider agreement.

In the context of Medicare enrollment, what is 'reassignment of benefits'?

Answer: Allowing another entity (e.g., a group practice) to bill for and receive Medicare payment for a provider's services

Reassignment of Medicare benefits allows a provider to authorize another entity, such as their group practice or employer, to submit claims and receive Medicare payments on their behalf.

A provider has been practicing for 30 years and is initial credentialing with a new hospital. Their malpractice carrier confirms coverage but states prior acts are not covered. What additional coverage should the credentialing specialist verify?

Answer: A tail policy or prior acts coverage to bridge the gap from previous policies

When a provider switches from a claims-made policy, a tail policy (extended reporting endorsement) or prior acts coverage is needed to cover claims arising from incidents that occurred before the new policy's inception date.