Common Reasons for Denials ✔ Incomplete documentation✔ License/DEA issues✔ Discrepancies in work history✔ Past malpractice claims Steps to Appeal Pro Tips for Success ✔ Respond Quickly –

1. Key Automation Tools ✔ Credentialing Software (e.g., Modio, IntelliSoft, MedTrainer)✔ CAQH ProView Integration – Auto-updates payer profiles✔ Document Management – Cloud storage with expiration alerts 2. What to Automate ✅ Application

1. Application Process ✔ Submit Request: Complete the hospital’s credentialing packet (varies by facility)✔ Required Documents: 2. Committee Review ✔ Medical Staff Services (MSS) verifies documents✔ Credentials Committee evaluates qualifications✔ Governing Board grants

Key Strategies 1. Centralized Credentialing System ✔ Single Source of Truth: Use credentialing software (e.g., Modio, IntelliSoft) to track: ✔ Document Storage: Cloud-based access to licenses, contracts,

Individual Provider Credentialing ✔ Covers single clinicians (MDs, DOs, NPs, etc.)✔ Required Documents: Group Practice Credentialing ✔ Covers entire organization (clinics, hospitals)✔ Additional Requirements: Key Considerations

Terminations ✔ Voluntary: Submit written notice (90-day notice typically required)✔ Involuntary: Due to non-compliance, license issues, or fraud✔ Notify Payers: Medicare (PECOS), Medicaid (state portal), commercial (CAQH)✔ Patient Transition

1. Centralized Tracking Tools ✔ CAQH ProView: Monitors commercial payer progress✔ PECOS (Medicare): Check application status online✔ Spreadsheet/CRM: Log submission dates, contacts, follow-ups 2. Proactive Follow-Up 3. Red

State Payers (Medicaid) ✔ Single Application per state✔ State-Specific Rules (varies widely)✔ Slower Processing (30-120 days)✔ Mandatory Updates for license/address changes Commercial Payers (Private Insurers) ✔ Payer-Specific Applications (each requires separate submission)✔ Faster Approval (30-60 days typically)✔ CAQH

System Purpose Managed By Frequency NPI Unique 10-digit ID for all providers CMS One-time (lifetime number) PECOS Medicare enrollment/revalidation CMS Every 5 years (Medicare) CAQH

Re-credentialing is required every 2-3 years (varies by payer) to maintain network participation. When to Re-Credential ✔ Medicare: Every 5 years (but update changes ASAP)✔ Medicaid/Private Payers: Typically every 3