May 2004 Table of Contents

GETTING PAID

Simplifying the Credentialing Process



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A new system replaces multiple plan-specific applications with one universal form.

Fam Pract Manag. 2004 May;11(5):24-25.

Administrative hassles imposed by insurance companies have contributed to increased professional dissatisfaction for many family physicians. One redundant and time-consuming task has been the need to complete separate credentialing applications for each insurance plan with which a physician contracts. Fortunately, a new solution may ease some of the burden associated with the credentialing process.

Universal credentialing

To help streamline the credentialing submission process, the Council for Affordable Quality Healthcare (CAQH), a not-for-profit alliance of the nation’s leading health care plans and networks, has developed a single credentialing application and common application database. Instead of having to submit separate applications to each managed care organization, physicians can use the Universal Credentialing DataSource system to submit a “universal” credentialing application either electronically or in hard-copy format. The data from the completed application is housed in a central repository that can then be accessed by participating health plans authorized to do so by the physician. Currently, the Universal Credentialing DataSource system is “live” in 43 states and the District of Columbia. It is expected to be introduced in the remaining seven states (Oregon, Michigan, Nevada, Utah, New Mexico, Arkansas and Massachusetts) within the year.

How does it work?

Physicians in participating health plans automatically receive a Provider ID that gives them free access to the universal credentialing application online (for a list of these plans, see “Participating organizations”). Physicians who don’t automatically receive a Provider ID should contact the health plan or the CAQH help desk at 888-599-1771. It’s important to note that although participating health plans use the same application data to credential physicians, each retains its own standards for evaluating the information. Completing the application will take the average physician about two hours (slightly more time is required if the physician has been practicing for a long time). The system uses prompts to guide physicians through the application process and runs a comprehensive audit to check for errors once the application is complete. It is not necessary to complete the electronic application in one sitting. Physicians can begin to fill it out, save what they have completed and go back to it anytime.

After the initial application is submitted, regular maintenance of the data is all that’s required. Using their Provider ID, physicians can update their information online or by fax at any time. The system also automatically notifies physicians once each quarter to confirm that the data on file is complete and accurate. CAQH’s Practice Administrator’s Module (https://caqh.geoaccess.com/pmm) makes the data entry task much easier for office managers or clinic administrators whose responsibilities include gathering credentialing information.

PARTICIPATING ORGANIZATIONS

The following organizations are currently participating in the Council for Affordable Quality Healthcare's Universal Credentialing DataSource:

Aetna

Anthem Blue Cross and Blue Shield

AultCare

Blue Cross Blue Shield of Georgia

Blue Cross Blue Shield of Kansas City

Blue Cross Blue Shield of Michigan

Blue Cross Blue Shield of Missouri

Blue Cross Blue Shield of North Carolina

Blue Cross of California

CareFirst BlueCross BlueShield

CIGNA HealthCare

Community Care Physicians

Culpeper PHO

Empire HealthChoice

Excellus Health Plans

The First Health Network / CCN Network

Great-West HealthCare / One Health Plan

HealthLink

Health Net

Horizon Blue Cross Blue Shield of New Jersey

Kaiser Foundation Health Plan of The Mid-Atlantic States

MAMSI Health Plans

MultiPlan

Oxford Health Plans

Preferred Care

Rocky Mountain Health Plans

Sentara Healthcare

UNICARE

Univera

Virginia Premier

Aetna

Anthem Blue Cross and Blue Shield

AultCare

Blue Cross Blue Shield of Georgia

Blue Cross Blue Shield of Kansas City

Blue Cross Blue Shield of Michigan

Blue Cross Blue Shield of Missouri

Blue Cross Blue Shield of North Carolina

Blue Cross of California

CareFirst BlueCross BlueShield

CIGNA HealthCare

Community Care Physicians

Culpeper PHO

Empire HealthChoice

Excellus Health Plans

The First Health Network / CCN Network

Great-West HealthCare / One Health Plan

HealthLink

Health Net

Horizon Blue Cross Blue Shield of New Jersey

Kaiser Foundation Health Plan of The Mid-Atlantic States

MAMSI Health Plans

MultiPlan

Oxford Health Plans

Preferred Care

Rocky Mountain Health Plans

Sentara Healthcare

UNICARE

Univera

Virginia Premier

Is it secure?

The Universal Credentialing DataSource database is housed in a secure data center maintained by the CAQH, and no one can access a physician’s information unless he or she has previously authorized it. Electronic signatures are required for Internet access and all online information exchanges are automatically encrypted using 128-bit Secure Socket Layer encryption. More detailed information on the security features of the application can be found at the CAQH Web site.

A caveat

Because only a fraction of the nation’s health care organizations are currently participating in the CAQH program, not all physicians will be able to benefit from this streamlined credentialing process. But all indications are that the number of plans participating in this program will grow. The universal credentialing application is an idea whose time has come. It’s free, saves time and paperwork hassles, and gives physicians more time to concentrate on what’s most important: their patients.

James Bare is a policy analyst for the American Academy of Family Physicians.

Conflicts of interest: none reported.

Send comments to fpmedit@aafp.org.

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