Credentialing Services

The Vendor is required to provide comprehensive provider enrollment, payer credentialing, Primary Source Verification (PSV), compliance monitoring, and related credentialing support services.
- Services shall include, but are not limited to, provider enrollment, payer credentialing, recredentialing, Primary Source Verification (PSV), expirable monitoring, sanction monitoring, agency maintenance, payer follow-up, issue resolution, and associated administrative support.
- Credentialing Services
• Manage the full end-to-end provider enrollment and credentialing process.
• Conduct and maintain primary source verification (PSV).
• Perform all aspects of provider credentialing and enrollment functions including:
• Initial credentialing
• Recredentialing
• Enrollment applications
• Monthly monitoring of expirable items
• Sanction monitoring
• Ongoing maintenance activities
• Access, maintain, and manage all required provider data and documentation necessary for payer enrollment and credentialing.
• Prepare, organize, maintain, and support required documentation necessary for enrollment and credentialing activities.
• Ensure compliance with all applicable state requirements, federal requirements, accreditation standards, regulatory requirements, and health plan requirements.
• Monitor enrollment applications and conduct follow-up with payers until approval and effective dates are obtained.
• Assist in resolving issues impacting provider participation, claims processing, reimbursement, credentialing status, or enrollment.
• Meet regularly with health to provide status updates, reporting, performance metrics, and operational reviews.
• Report expiring credentials, sanctions, compliance concerns, enrollment delays, and other critical issues promptly to health.
• Provide the ability to process urgent or expedited files for new hires or operationally critical providers.
• Facilitate contracts and enrollment activities with managed care organizations (MCOS), commercial payers, and governmental payers for rural health clinic operations.
• Maintain accurate records and documentation for all credentialing and enrollment activities.
• Maintain confidentiality and security of all provider, patient, and organizational information.
• Coordinate with health staff regarding missing information, provider updates, payer requirements, and operational needs.
• Maintain professional communication standards with all stakeholders including providers, payers, health personnel, and regulatory entities.
• Ensure timely completion of all required activities.
• Provide management oversight of all assigned credentialing and enrollment activities.
• Maintain sufficient staffing levels to meet operational requirements and turnaround expectations.
• Ensure continuity of operations throughout the term of the contract.
- Provider enrollment services
• Complete payer enrollment applications for government and commercial payers.
• Enroll providers with applicable governmental and commercial health plans.
• Verify provider licenses, certifications, registrations, and required documentation during the enrollment process.
• Prepare and submit enrollment documentation accurately and timely.
• Track all enrollment applications through completion.
• Follow up with payers regarding pending enrollment applications.
• Obtain enrollment approvals and effective participation dates.
• Resolve enrollment issues impacting provider participation, billing, claims reimbursement, network participation, or effective dates.
• Maintain documentation supporting enrollment status.
• Conduct all enrollment activities in accordance with payer guidelines and requirements.
• Communicate regularly with health regarding enrollment progress and status.
• Maintain and update provider information as necessary.
• Maintain and update health profiles and associated documentation.
• Upload and maintain supporting documentation required by payers.
• Assist with enrollment issue resolution activities.
• Coordinate provider demographic updates and changes with payers.
• Monitor revalidation and reenrollment requirements.
• Maintain detailed tracking records for all enrollment activities.
• Ensure enrollment activities are completed within payer-required timelines.
• Escalate enrollment delays or barriers to health as appropriate.
- Payer Credentialing Services
• Conduct credentialing for initial appointments.
• Conduct recredentialing and reappointment activities.
• Perform primary source verification (PSV) activities.
• Conduct verification of licenses, certifications, education, training, board certifications, DEA registrations, malpractice coverage, and other required credentialing elements.
• Conduct data entry and data management activities.
• Prepare credentialing files and upload required documents into designated systems.
• Retrieve, organize, and submit credentialing files.
• Conduct file audits for compliance, completeness, and accuracy.
• Perform follow-up activities related to incomplete or returned files.
• Monitor provider credentials for expirations or compliance issues.
• Conduct sanction monitoring activities.
• Conduct regular checks of federal and state sanction databases including:
• Office
• System for award management (SAM)
• Bank where applicable
• Other required databases
• Maintain documentation of all verification activities.
• Update expirable documents and records as required.
• Maintain credentialing records in accordance with applicable requirements.
• Monitor performance and operational outcomes.
• Ensure credentialing files meet payer and accreditation requirements.
• Assist health with credentialing issue resolution.
• Coordinate with providers regarding missing or expiring documentation.
• Ensure credentialing activities are completed within required timeframes.