Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities

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Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities

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Credentialing for Managed Care:
Compliant Processes for Health Plans and Delegated Entities

Amy M. Niehaus, CPMSM, CPCS, MBA

New to managed care credentialing? Whether you work for a health plan or a hospital medical staff services department, this how-to guide answers all of your health plan credentialing and enrollment questions. Learn the regulatory and accreditation requirements related to managed care credentialing, including those from CMS, NCQA, and URAC. Author Amy M. Niehaus, CPMSM, CPCS, MBA, provides readers with the guidance to create a comprehensive and compliant credentialing program to support your health plan or to streamline your hospital’s provider enrollment process through delegation. MSPs in all healthcare environments can benefit from understanding credentialing in the managed care world to support their organizational goals of compliance, operational efficiency, cost savings, and practitioner satisfaction.

This book will help you:

  • Understand NCQA, URAC, and CMS requirements for health plans
  • Develop a comprehensive and compliant managed care credentialing program
  • Establish delegated credentialing agreements
  • Audit credentials files
  • Recognize how payer credentialing requirements impact other healthcare organizations
  • Streamline provider enrollment through delegation
  • Identify the differences between hospital and managed care credentialing
  • Evaluate whether a credentials verification organization is right for your organization


About the Author:

Amy M. Niehaus, CPMSM, CPCS, MBA, is a consultant with The Greeley Company, an industry-leading healthcare consulting firm. She has over 25 years’ experience in the medical services and credentialing profession. In her current role, she advises clients in the areas of accreditation, regulatory compliance, credentialing, process simplification and redesign, credentialing technology, and credentials verification organizations (CVO) development and delegation. Niehaus has worked in multiple environments throughout her career, including acute care hospitals, CVOs, and managed care organizations (MCO). She has been a member of the National Association Medical Staff Services (NAMSS) since 1991 and achieved her CPMSM certification in 1992 and her CPCS certification in 2002. Niehaus is a NAMSS instructor and previously served as chair of its MCO Task Force, as well as chair and member of the NAMSS Education Committee. She is a former president of the Missouri Association Medical Staff Services and its greater St. Louis area chapter. Niehaus holds a bachelor’s degree from the University of Missouri and a master’s degree in business administration from Maryville University in St. Louis. Niehaus has developed and presented various programs to local and national audiences on topics such as credentialing and privileging processes; Joint Commission, National Committee for Quality Assurance (NCQA), and URAC accreditation standards; and delegation.

Published: August 2016 

Page count: 200
Dimensions: 8.5x11
ISBN: 978-1-68308-080-0

Table of Contents

Chapter 1: Overview of the Managed Care Environment

  • Health Plan Credentialing Process
  • Accreditation
  • Regulatory Requirements
  • Key Legislation
  • Legal Precedent


Chapter 2: Accreditation and Regulatory Requirements

  • NCQA
  • URAC
  • CMS


Chapter 3: Verification Requirements

  • Verification Time Frames
  • Methods of Verification
  • Licensure
  • DEA or CDS
  • Education and Training
  • Board Certification
  • Admitting Privileges
  • Work History
  • Malpractice Insurance
  • Malpractice History
  • License Sanctions
  • Medicare/Medicaid Sanctions
  • Application and Attestation


Chapter 4: The Credentialing Process

  • Application Process
  • Verification Process
  • Review Process
  • Decision Process
  • Post-Approval Processes
  • Differences From Hospital Credentialing


Chapter 5: Delegated Credentialing

  • Delegation Process
  • Hospitals, Health Systems, and Delegated Credentialing
  • Delegation Collaboration
  • Challenges to Delegated Credentialing
  • Achieving Delegation Success
  • Delegated Credentialing Tools and Forms


Chapter 6: Credentials Verification Organizations (CVO)

  • Brief History of CVOs
  • CVO Services
  • Overview of CVO Certification/Accreditation
  • National Practitioner Data Bank Requirements


Chapter 7: Test Your Knowledge

Chapter 8: Tools and Resources