Network Provider Credentialing 101 May 2012

Learning Objectives Upon completion of today’s presentation, you should: 1) Be familiar with the TRICARE certification and TRICARE credentialing processes. 2) Understand what it means to be a TRICARE network provider. 3) Be able to locate online resources, including the Council for Affordable Quality Healthcare (CAQH®) online system and the Provider Information Form.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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About TRICARE TRICARE is … the health care program supporting active duty service members, National Guard and Reserve members, retirees, family members, survivors and certain former spouses worldwide. … a network of military and civilian health care professionals working together to foster, protect, sustain and restore health for those entrusted to their care.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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TRICARE North Region Health Net Federal Services, LLC (Health Net) is honored to continue our service to nearly three million beneficiaries in the TRICARE North Region. We thank you for caring for and supporting our nation’s heroes.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Provider Types AUTHORIZED PROVIDER

NON-AUTHORIZED PROVIDER

NETWORK PROVIDER

NON-NETWORK PROVIDER

(signed agreement)

(no signed agreement)

SIGNS PRIME CONTRACTOR AGREEMENT ACCEPTS TRICARE NEGOTIATED PAYMENT FILES CLAIM FOR MEMBER

TRICARE CANNOT PAY

PARTICIPATING

NON-PARTICIPATING

(accepts assignment, i.e., TRICARE payment in full)

(does not accept assignment or TRICARE payment in full)

PARTICIPATES ON CASE-BY-CASE BASIS

MAY FILE CLAIM FOR MEMBER

FILES CLAIM FOR MEMBER MAY NOT BALANCE BILL

(if not, member must file)

MAY BALANCE BILL UP TO 115% OF TRICARE-ALLOWABLE CHARGE BENEFICARY RECEIVES PAYMENT FROM TRICARE

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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TRICARE Certification TRICARE only reimburses TRICARE-authorized, also referred to as TRICARE-certified, providers. • In many cases, providers can see TRICARE patients and file claims with TRICARE to initiate the certification process. • Certified providers must meet TRICARE licensing and certification standards and must comply with regulations specific to their health care areas. • Certified providers are considered non-network TRICARE-authorized providers unless they become TRICARE network providers.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Credentialed Provider Credentialed providers sign an agreement and become members of the TRICARE Prime network. Credentialing involves, but is not limited to, a review of: • Education. • Board certification. • License. • Professional background. • Professional liability insurance. • Malpractice history.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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What is a network provider?

A TRICARE network provider is a credentialed civilian provider who has signed an agreement with Health Net or MHN—the behavioral health network for Health Net—to be part of the network of providers who participate in the TRICARE program.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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The Role of a Network Provider Network providers … • Serve an important role in TRICARE by complementing the services offered by military treatment facilities (MTFs). • Typically receive higher TRICARE patient volume than non-network providers. • Agree to a negotiated rate as payment in full for services rendered.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Primary Care Managers Primary care manager (PCM) network providers must also: • Provide 24-hour medical coverage. • Agree to refer health plan members for specialty care, when necessary.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Starting the Process • You must have a network agreement on file with Health Net to begin the credentialing process. • Medical/surgical providers who are interested in becoming network providers can contact Health Net at 877-TRICARE (877-874-2273) to obtain a contracting packet.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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CAQH® Health Net is a full participant in the Council for Affordable Quality Healthcare (CAQH®) Universal Credentialing Datasource® (UCD) initiative. Visit www.caqh.org. • This online tool streamlines the credentialing process for individual network providers. • There is no cost to submit an application and participate with CAQH.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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CAQH® It is a requirement to use CAQH to join our network.

• If you do not have a CAQH number, you may send us a Provider Information Form (and a network agreement if a new provider) and Health Net will initiate the request for a CAQH number for you. • Please keep your CAQH file current, as that is the biggest delay in the credentialing process.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Provider Information Form In addition to the CAQH application, TRICARE network applicants must also submit a supplemental Provider Information Form*, found on www.hnfs.com and included in all contract packets mailed to providers requesting new agreements. This Provider Information Form includes information unique to TRICARE and not addressed within the CAQH application.

* Does not apply to TRICARE Standard provider applicants

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Submitting the Provider Information Form • Prior to June 1, 2012 – Fax or mail to the appropriate Health Net sub-regional office as noted on www.hnfs.com. • On or after June 1, 2012 – Fax to our new centralized fax number, 888-428-8710. We are currently updating the Provider Information Form and the initial process to participate as a network provider. We will update www.hnfs.com as soon as these changes are finalized. TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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How long is the process? • The full credentialing process may take 90-180 days from the time we receive a complete application. • When the credentialing process is complete, you will receive written (email) notification from Health Net of the results. • If you are approved for TRICARE network participation, we will send a fully executed copy of your participation agreement.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Adding Providers to Your Group CAQH makes adding providers to your network group quick and easy. • New members of your group can update their CAQH profile and submit a Provider Information Form to Health Net. • If your new group member is not registered with CAQH, simply complete the Provider Information Form, forward it to Health Net and they will be invited by CAQH to participate in its process.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Behavioral Health Networks What are the requirements for behavioral health network providers? While medical/surgical network providers are contracted through Health Net, most behavioral health network providers are contracted through MHN. Behavioral health providers should visit www.mhn.com and click on Provider Site for more information about behavioral health network provider contracting.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Keystone Peer Review Keystone Peer Review Organization, Inc. (KePRO) is the quality monitoring contactor for TRICARE. The following facilities must first become certified by KePRO before completing the network provider contracting process with MHN.

• Behavioral health freestanding Partial Hospital Programs. • Residential Treatment Centers. • Substance Use Disorder Rehabilitation Facilities.

Contact KePRO at 800-222-0771 or www.kepro.com

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Credentials Review Health Net conducts a credentials review on each network provider to determine if the provider meets the minimum requirements of TRICARE Management Activity, Health Net and URAC. • A full re-credentialing review of all contracted health care providers is conducted every three years.

• Health Net retains the right to terminate any provider contract.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Specialty Updates There may be times between credentialing cycles when it is appropriate to add, change or delete a specialty description as represented in the Network Provider Directory. These specialty updates can be requested online*. Health Net’s Credentialing Department will review and process all requests received. *Registration on our website is required.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Provider Demographics Update Form The Provider Demographics Update Form is an interactive PDF that allows network providers to update: • Practice address. • HIPAA-compliant referral and authorization fax number. • Tax Identification Number. • Billing address. • Main point-of-contact email address.

You may also: • Add a location.

• Delete a location. • Delete a practitioner.

Keeping your information current allows us to provide the most up-to-date information in our Network Provider Directory. TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Additional Information Much of the information provided today can be found on our website, www.hnfs.com.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Additional Information

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Online Provider Education TRICARE North Region Provider Handbook – Paperless and available at www.hnfs.com.

Online Tools Tutorial – A step-bystep guide to online tools currently available on our website.

Webinars – Live briefings offered every other week. Recorded briefings and downloadable presentations also available.

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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Questions and Answers

TRICARE is a registered trademark of the TRICARE Management Activity. All rights reserved.

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