Reimbursement Credentialing

Reimbursement Credentialing

Many RWHC members and other rural organizations submit professional fees for the services provided by their practitioners. This is a complex process as the average rural organization has more than 10 health plan contracts. Each health plan has its own requirements and process for enrolling new practitioners as health plan providers. In addition, practitioners must be enrolled as a Medicare and Medicaid provider with yet a different set of requirements and process.

The RWHC Reimbursement Credentialing Service can assist organizations with provider enrollment (and maintenance of enrollment) for each of their health plan contracts. To accomplish this, RWHC works with a contact at the organization and/or with the practitioner directly along with identifying specific contacts and web links for each health plan. RWHC clarifies what each payer requires; completes the required screening and subsequent applications and provides all necessary follow-up including confirmation of enrollment and the effective date.

A similar process is established for the recredentialing process, typically every 3 years that each health plan requires. This service also includes establishing and maintaining the national CAQH application now required by most of the larger health plans. In addition, RWHC manages any demographic changes that may occur for each of the individual practitioners.

The RWHC Reimbursement Credentialing Services is limited to those organizations contracting for the RWHC CVO Service. This is to assure that RWHC has the current and accurate data to complete and maintain the provider enrollment process for each health plan.

The Reimbursement Credentialing Services has an initial enrollment fee for new practitioners that includes all tasks for provider enrollment and an annual subscription fee for established practitioners that provides the ongoing maintenance required by many plans (e.g. CAQH Updates) and recredentialing requirements.

For additional information about reimbursement credentialing, contact Bonnie Laffey at (608) 643-2343.