Provider Enrollment and Credentialing - 4 Part Complete Series for 2025

Medicare Provider Enrollment 101: Complete Enrollment and Credentialing Process for Providers

Do you know that credentialing and payer enrollment are the cogs that kick-start the revenue cycle of your organization? Payer/Provider Enrollment includes the payer-specific process to enroll your organization and provider with in-network participation. In-network participation equals in-network reimbursement for services rendered. Additionally, Provider enrolment has many moving parts that must be managed successfully because your organization’s bottom line depends on it. In provider enrolment, we must successfully and continuously maintain multiple provider profiles, directories, network portals, etc. You must update and revalidate information correctly. Any missed process in the cycle can negatively impact the provider's network participation and the organization’s revenue cycle. This session will review the most common provider enrollment web portals and forms and how to manage them successfully. Expert Yesenia Servin, CPMSM, PESC will analyze provider enrolment, revalidation, and attestation and the impact they have on your organization’s revenue.

Enrolling with the Medicare program involves the various CMS-855 forms. There are now different forms that must be used by different providers of healthcare services or products. These forms are long, detailed, and sometimes confusing. Not only must they be filed initially for a given provider, they must be maintained and updated as appropriate. Due to the increasing complexity of healthcare delivery systems, providers, such as integrated delivery systems or large multi-specialty clinics, may have to maintain hundreds of these forms. Join expert Yesenia Servin, CPMSM, PESC, for this detailed review of the CMS 855 forms for Medicare participation. We will review both the paper applications and PECOS applications, Facility apps, Organization apps, and Individual apps. Failure to use the updated forms can cause outright rejection of the application and lead to significant delays in getting your providers enrolled.

Learning Objectives:-

• Overview of CMS connection in order to remain compliant and to successfully complete Medicare provider applications
• Understand part A Facility applications
• Understand part B organization app and individual apps
• Understand reassignment apps
• To review the Medicare enrollment process through the use of the various CMS-855 forms
• To address changes to the CMS-855 forms and/or changes in interpretations of the forms
• To discuss the revalidation process for the various CMS-855 forms
• Review each section of the application within PECOS
• Know the payer-specific rules and requirements of both government and commercial payers.

Areas Covered in the Session:-

• Health & Affirmations
• Defined & Explained
• • Credentialing
  • Enrollment
• Joining the Network
• • Pre-application
  • Network screening
  • Network invitation
  • Application/Agreement
  • Provider submission
  • current CAQH account
  • The network performs all phases of the process
  • Final determination; INN or denial
• First Actions Steps
• • Name
  • TIN vs SSN
  • Identity & Access (I&A)
  • • NPI
    • NPPES
    • Specialties
    • PECOS
  • CAQH
  • CPT List
  • Fee schedule
• I&A Identity & Access Account
• CAQH & NPI
• Documentation
• Discovery Phase: Why
• Discovery Phase: Who
• Discovery Phase: Where
• Discovery Phase: When
• Portals & Profiles
• • Payer Network Portals
  • • Government Portals
    • Private Portals
  • Hospital Portals
  • Clearinghouse & Directory portals
• Defined: Delegated & Non-Delegated
• Build Your Own Credentialing Database
• • Build your own database; Excel, Access, OneNote, etc
  • Everything that is listed on your CAQH profile Maintain Employment History
  • New Opportunities
  • More Why’s?
  • Network information
  • Contract ID & Login
  • Communications details
  • Details of pre-app submission, full agreement submission Follow-up
  • Approval/Denial
  • Confirmation of Fee Schedule
  • I&A, NPPES login info
  • Completed training/internships
  • Expirable information
• CMS Connection (Access Manager) to all EINs
• Availity Connection
• Access to payer platforms, i.e., UHC, Cigna.

Who will Benefit:-

• Credentialing Specialist
• Revenue Cycle Managers
• Enrollment Specialist
• Hospitals
• Mental Health Providers
• LCPC
• LMFT
• Practice, Clinic Owners
• Hospital Leadership
• Authorized Officials
• Delegated Officials
• Revenue Cycle Directors
• Credentialing
• Office Manager
• Revenue Cycle
• Operations
• Billing Team
• In and Out of Network Providers
• Medical Billing Companies
• Providers Office Staff
• Physician
• Hospitals and Facilities
• Insurance Companies
• Healthcare Attorneys
• Executive and Administrators
• Front Desk
• Scheduling
• Authorizations Staff
• Medical Assistants
• Certified Nursing Assistants

Credentialing and Provider Enrollment 102

This is the second session of our Credentialing and Enrollment series. Yesenia presents this detailed, comprehensive webinar, teaching you to successfully credential your providers and mid-level providers. This webinar features a complete step-by-step guide to provider credentialing, including customizable forms for payer/application cover letters, provider documentation requirements, Verification of Documentation, CV requirements, application submission, payer linkage, provider revalidation, employment history, and much more! You will be provided tracking tools to aid in the tracking/verification of provider documents and payer application tracking.

• Provider Documentation Requirements
• Verification/Validation of Provider Documents
• Provider Document Tracking
• Setup/Maintenance of Provider File
• Setup/Maintenance of CAQH, PECOS, NPPES, I/A
• Provider Portals & Profiles
• Payer application requirements
• Payer application prep/submission
• Payer-specific enrollment information
• Payer application tracking
• Medicare/Medicaid Enrollment
• Provider Linkage to Payer
• Efficient and Timely Communication
• Steps to complete once the provider is approved by the payer
• Multiple Printable/Customizable Forms, Letters, Tracking Tools
• Live Q&A Session.

Learning Objectives:-

• Setup/Maintenance/Attestation of CAQH, PECOS, NPPES, I&A
• How to complete the payer enrollment applications
• Follow-up process for provider enrollment applications
• Payer-specific requirements for applications and submission
• Payer-specific contact and submission information
• Tracking of payer enrollment application packages.

Areas Covered in the Session:-

• CMS PECOS
• Medicare application
• Medicare revalidation
• Medicare
• DME
• Ordering & Prescribing
• Mental Health Providers
• LCPC, LMFT
• RHC, RHE, Hospitals
• MACs
• CHOW
• Organization ownership data
• NPI Profile
• CAQH
• Workflow
• Provider Enrollment
• Credentialing
• EFT.

Who will Benefit?

• Practice Managers
• PESC
• CPMSM
• Revenue Cycle
• Directors
• CFO
• Credentialing
• Provider Enrollment
• EFT Enrollment
• Operations.

Credentialing and Provider Enrollment 103

CMS Identity & Access Step-by-Step Walk-through

NPPES Step by Step

The NPPES interface is complex and confusing. Your organization and providers' CMS National Plan and Provider Enumeration System (NPPES) account is about so much more than just acquiring a National Provider Identifier (NPI), but maintaining it accurately and compliantly can be confusing and frustrating. Whether you have just one or 50 accounts to manage, you can improve your results with expert guidance from nationally certified credentialing specialist, Yesenia Servin, CPMSM, PESC.

• Review that the taxonomy details are accurate.
• What if your application gets denied or rejected?
• What if your claims are being labeled as out of Network, but you have an in-network approval?

Learning Objectives:-

• Setup/Maintenance/Attestation of NPPES, I&A
• How to complete the payer enrollment applications
• Follow-up process for provider enrollment applications
• Payer-specific requirements for applications and submission
• Payer-specific contact and submission information
• Tracking of payer enrollment application packages
• • Create a strong I & A to securely access CMS systems such as NPPES & PECOS
  • Utilize the surrogacy program to easily manage multiple NPPES accounts within your own account
  • Accurately and efficiently complete an NPPES registration on the first try
  • Manage multiple NPI profiles within your own account
  • Understand specialties and taxonomies

Who Will Benefit?

• Practice Managers
• PESC
• CPMSM
• Revenue Cycle
• Directors
• CFO
• Credentialing
• Provider Enrollment
• EFT Enrollment
• Operations.

Provider Enrollment 104

Insurance Credentialing 104In this session, we will explore the advanced components of the provider enrollment process with a focus on operational efficiency and compliance. Key topics will include tracking enrollment timelines, navigating healthcare plans and product structures, and managing provider data through reporting and rostering tools. We will also delve into government payer processes and requirements, highlighting the distinctions between commercial and public programs.Attendees will gain practical insights into streamlining enrollment workflows, ensuring data accuracy, and maintaining alignment with regulatory standards across the various payers.Learning Objectives: -Identify key timelines, payer requirements, and documentation needed to successfully complete provider enrollment across commercial and government health plans.Demonstrate an understanding of effective tracking, reporting, and rostering practices to ensure compliance and data accuracy throughout the provider enrollment processAreas Covered:-

• NPI
• NPPES
• Medicare
• Medicaid
• Credentialing
• Enrollment
• Locums
• Enrollment Process
• Provider Rosters
• Timeline tracking
• Reporting
• Turnaround Time
• CAQH

Background: -Build on the credentialing and enrollment processes you have already learned and implemented.Who Will Benefit?

• Practice Managers
• PESC
• CPMSM
• Revenue Cycle
• Directors
• CFO
• Credentialing
• Provider Enrollment
• EFT Enrollment
• Operations.