Credentialing is the process by which the appropriate committee reviews documentation for each individual physician/provider to determine participation in the health plan network. Such documentation may include, but is not limited to, the applicant’s education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history, professional competency, and physical and mental impairments. The credentialing process includes verification that the information obtained is accurate and complete. The physician/provider must respond to any reasonable CarePlus Health Plans, Inc. (CarePlus) request for additional information including, but not limited to, a medical record review as well as a site visit as applicable.
CarePlus recognizes the physician’s/provider’s right to review information submitted in support of the credentialing application to the extent permitted by law and to correct erroneous information. Providers may obtain information regarding the status of their credentialing or recredentialing process by calling CarePlus.
The credentialing process generally is required by law. The fact that the physician/provider is credentialed is no intended as a guarantee or promise of any particular level of care or services.
Council for Affordable Quality Healthcare (CAQH): CarePlus thru its parent company Humana Inc., is a member of the Council for Affordable Quality Healthcare (CAQH), which is an online single, national process that eliminates the need for multiple credentialing applications. Physicians/providers who are members of CAQH can provide CarePlus with the appropriate information in lieu of completing a CarePlus credentialing or re-credentialing application. Additional information may be requested.
CarePlus Credentials Committee: Is conducted at a corporate level thru its parent company in Louisville, KY. The Credentials Committee is composed of a chairperson and employed and participating physicians/providers. Functions of the committee include credentialing, ongoing and periodic assessment, recredentialing, and establishment of credentialing and recredentialing policies and procedures. The physician’s/provider’s documentation is provided to the corporate credentials committee for approval or denial for participation in the network. Notification of approval or denial of credentials is sent to the physician/provider.
Recredentialing: Recredentialing is conducted at least every three (3) years in accordance with the CarePlus credentialing and recredentialing process. The recredentialing process is conducted with the same standards as those for initial credentialing. The decision concerning re-appointment or failure to re-appoint will be conveyed to the physician/provider in writing.
Medicare Guideline posts
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Top Medicare billing tips
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee...
CPT CODE and description 90460 - Immunization administration through 18 years of age via any route of administration, with counseling by ...
Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immun...
CPT CODE and Description 97001 - Physical therapy evaluation Average fee payment $70 - $80 97002 - Physical therapy re-evaluation Ave...
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
CPT CODE and Description 90785 - Interactive complexity (List separately in addition to the code for primary procedure) 90791 - Psychi...
Here is the big list of Medical terminology abbreviation @—at A & P—anatomy and physiology ab—abortion abd—abdominal ABG—arterial ...
Place of Service: A two-digit code used on health care professional claims to indicate the setting in which a service was provided. Place...
Complete Blood Count (CBC) Testing A complete blood count consists of measuring a blood specimen for levels of hemoglobin, hematocrit, red...
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 36416 Collection of capi...