Credentialing and Payor Enrollment
Phase 1: The initial step is the Application Completion process. We make this process as seamless as possible, so you don’t have to fill out duplicate applications.
o You will get a link to a portal. You will sign into your CAQH account, update and attest your CAQH profile.
o After you have updated your profile, we will have secure access to the necessary information to create the Texas Standardized Credentialing Application (TSCA).
o Next step in this first phase, is for us to start the credentials verification process in accordance to NCQA, CMS, and Health Plan guidelines.
o After this comprehensive verification is done, your file will go to our Peer Review Committee for their review and approval.
o After Peer Review Committee approval, you will get a notification that your credential verification is done and Genesis Health Plan enrollment team will take over. This initial phase is significantly dependent upon how quickly you are able to accurately update and attest your CAQH profile. Our goal is for this initial process not to take more than 30 days.
Phase 2: The Second Phase is Health Plan enrollment with the goal of obtaining effective dates so you can compliantly see patients and submit bills to Health Plans for reimbursement.
o Turnaround time for each health plan varies. After Genesis’ Peer Review Committee approval, health plans can take up to 145 business days to issue effective dates. Many health plans back-date the effective date to when we submit the information but there are no guarantees on this.
We currently do not offer Medicaid and Medicare Enrollment services. For Medicaid and Medicare enrollment please refer to the following instructions:
For Medicaid: Please go to Texas Medicaid Healthcare partnership site: www.tmhp.com log into your account and follow the instructions to revalidate.
For Medicare: Please go to PECOS (Medicare Provider Enrollment, Chain, and Ownership System) site: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 log into your account and follow the instructions to revalidate.
CAQH is important for several reasons:
1. Credentialing and Provider Data Management: CAQH operates a centralized database where healthcare providers can securely store and maintain their credentialing and provider data. This eliminates the need for providers to submit redundant credentialing paperwork to multiple health plans and organizations.
2. Efficiency: By using CAQH, providers save time and effort when applying for network participation with various health plans. It simplifies the process, reducing administrative overhead and paperwork.
3. Accuracy: The database helps ensure that provider information is accurate and up to date, which is crucial for Credentials Verifications Organizations (CVO) such as Genesis Physicians Group to verify the qualifications of our members to effectively enroll you in health plans.
4. Compliance: Many states, including Texas, require the use of standardized credentialing applications like the Texas Standardized Credentialing Application (TSCA). CAQH helps providers meet these compliance requirements by providing the necessary standardized information.
In summary, CAQH plays a vital role in streamlining administrative processes, improving data accuracy, and reducing administrative burdens in the healthcare industry, making it an essential tool for both healthcare providers and Genesis Physicians Group’s Credentialing and Provider Enrollment team.
Genesis’ responsibilities don’t end after health plans’ effective dates are obtained. Our 18+ health plans require us to do ongoing monitoring of sanctions, National Practitioner Data Base, etc. and provide them regular reports. This ongoing monitoring is an essential responsibility for our team to ensure you don’t have any lapses in your health plan enrollment to avoid any interruption in the flow of your revenue.
In addition to the responsibility of ongoing monitoring, we undergo audits by health plans annually.
As you can imagine this is a cumbersome process. Based on the result of the audit we modify our credentialing policies and procedures annually. In addition to multiple health plan audits we undergo an extensive NCQA audit every other year. The NCQA audit takes 3 to 4 months to complete. As a result of the NCQA audit, we modify and update our policies and procedures.
Every three years we re-credential our members based on regulatory compliance requirements. The process includes primary source verification of credentials ensuring all of the physician’s credentials such as malpractice, DEA, licenses, etc. are up to date.
We do not provide Revenue Cycle Management services. We are not able to assist with claims questions unless it is regarding network status (claims processed as out of network), fee schedules, or demographic issues (locations not listed with the plans).
Genesis Agreements with Health Plans do not have hard expiration dates. They are essentially evergreen and auto-renewing. As a messenger IPA model, by law we are not allowed to negotiate rates.
Almost all the contracts state that fee schedules can be “updated periodically” by the plan. In fact, It is quite common for fee schedules to only change every few years with the exception of addition of newly published codes or new drugs/injectables which are updated more frequently.
Genesis does not hold the Health Plan agreement directly with United Healthcare. Per United Healthcare’s policy, they contract directly with you as the Healthcare Provider. They do delegate the credentials verification and the enrollment processes to Genesis.
o If you have United Healthcare Contract questions, please contact Michelle Antisdel at firstname.lastname@example.org or call (952)202-7101.
o If you have United Healthcare Network questions, please contact email@example.com.
UHC Network questions may include:
o Fee schedule requests
o General contracting questions
o Network availability and product participation
o Status of provider/contract load
If you have demographic updates to your practice (office locations, phone numbers, Tax IDs, credentialing contact) please submit a request through the website https://genesisdocs.org.
o Click “Contact Us” and select Demographic Updates.
o We will respond with an anticipated timeline along with any additional clarifying questions to accurately make all the requested demographic updates.
In 2022, UHC introduced the Exchange Network as a new offering. Providers chosen to participate received notification letters along with an Amendment to their contract. UHC selected the providers included in the Exchange network through direct agreements with those providers.
Key Points to Note:
- UHC’s selection for this plan was specific and not open to all providers.
- If you haven’t received communication about this plan, you are not part of the in-network.
- Regrettably, Genesis does not have the capability to enroll you in this plan.
Please note that the current enrollment period for the exchange plan has ended. UHC conducts an annual review of the network and will send out amendments to selected providers for inclusion in this plan.