Credential Qualified Providers
Learning Objectives
After completing this unit, you’ll be able to:
- Describe the key steps of the credentialing process.
- Explain how Provider Network Management helps users at each step of the credentialing process.
Provider Credentialing
After a health plan recruits providers to its network, it must ensure that these providers have all the right credentials. In a provider context, credentials refer to all the licenses, certifications, education, and registrations a provider must have. In such a heavily regulated industry as healthcare, there are many required credentials so it’s important for payers to conduct a rigorous verification process.
With this credentialing solution, payer organizations can use prebuilt workflows and other tools to simplify and streamline credentialing tasks.
The key steps in provider credentialing are:
- Submit credentials.
- Review credentials.
- Verify credentials.
And here’s a brief summary of each step.
Step |
Summary |
|---|---|
Submit credentials. |
The prospective provider submits all the required credentialing information through an application workflow from their provider portal. Health plans can partner with a credentialing organization to greatly simplify this task, with most of the work done automatically after the provider enters his or her ID. |
Review credentials. |
After the provider submits the application, all the credentialing information automatically populates the provider’s contract record. From there, the credentialing specialist accesses and reviews all the submitted credentials in one central location. |
Verify credentials. |
Health plans verify credentials internally, partner with a third party, or use a hybrid approach with some details verified by a third party and others verified internally by the credentialing specialist. Guided workflows, pre-filled information, and knowledge article suggestions assist the credentialing specialist with manual verification items. For items handled by a third party, the health plan configures business rules to streamline the process and monitor status in real time. |
In the previous unit, you met Dr. Leila Zamadi, who was successfully recruited by Cumulus’s recruiting specialist. Let’s now see how Cumulus sets up a smooth process to help Dr. Zamadi move through the credentialing stage.
Submit Credentials
At the end of the recruitment phase, the recruitment specialist at Cumulus converts Dr. Zamadi’s lead record to a contact, account, and user. This conversion initiates the credentialing process. Dr. Zamadi automatically receives an email that invites her to join the provider portal.
She clicks the link, sets her password, and gains access to the portal.
Her portal is personalized, and all the tasks and information focus on credentialing. The portal presents her with a To Do List that provides a link to any unfinished tasks. Currently, Dr. Zamadi’s one-and-only action is to complete her provider application. She clicks the Complete Your Application button, launching a guided flow.
Dr. Zamadi enters her Centers for Affordable Quality Healthcare (CAQH) ID and her credentials appear automatically. CAQH is a credentialing database leader. The Provider Network Management data model supports integration with CAQH, which is enabled after Cumulus configures the connection and supplies its credentials. After entering her CAQH ID, Dr. Zamadi reviews her credentials and submits the form.
Her work here is now done! The same portal supports Dr. Zamadi across all other stages of her relationship with Cumulus, including contracting, onboarding, and ongoing support after she becomes a participating provider.
Cumulus has everything it needs to initiate verification of her credentials. Let’s see how it reviews credentials.
Review Credentials
Cumulus uses a hybrid approach to credential verification, with some details verified by a third party and others verified internally by credentialing specialists. Cumulus’s business rules require that a credentialing specialist must first review and confirm credential details before sending anything for third-party verification.
Since Cumulus maintains such a large provider network, it uses automation rules to route provider verification to queues based on a variety of provider attributes. Different credentialing specialists are then assigned to different queues. Dr. Leila Zamadi’s credentialing application routes to a queue for English-language credentialing cases.
Derek Brooks, the credentialing specialist at Cumulus, logs in for the day and reviews key metrics and cases on his home page. He’s a member of two verification queues, including the Credentialing English Language queue. He investigates Dr. Zamadi’s credentialing case at the top of his queue.
On Dr. Zamadi’s case record, a work guide clearly lists out the key tasks that Derek needs to complete. Derek’s supervisor designed this work guide using Salesforce’s Flow Orchestration tools. With Flow Orchestration tools, users can create work guides to simplify complex processes that involve multiple stages and users.
At the top of the record, a path tracks the stages of the credentialing process. Dr. Zamadi’s case currently sits in the Pre-Verification Check stage. Just as with the work guide itself, the implementation team can easily customize these paths to match a payer’s exact credentialing process.
Derek performs an initial check of Dr. Zamadi’s information by expanding the category blocks at the bottom of the work guide. Much of her information displays in green, but her work history appears in red due to some missing information. Derek makes a note to fill in this missing information.
With the initial review complete, it’s time to verify the credentials.
Verify Credentials
The credentialing specialist reviews the data first before sending certain key verification tasks off to a third party via API. For those manual verification items, Cumulus uses a number of Salesforce tools to speed things up.
When Derek Brooks validates the work and education history for Dr. Leila Zamadi, he does it with the support of guided workflows that have pre-filled information for validation and contextual knowledge article suggestions for each step.
All of the fields and values are fully customizable, and it’s easy to modify work guides to match your precise business process. For those items that require third-party verification, the credentialing specialist can easily check their real-time status. Ultimately, automated and specialist-led steps come together to efficiently complete credentialing for Dr. Leila Zamadi.
The credentialing process has also provided Cumulus with the insights needed to initiate the contracting experience, which comes next.
Resources