Contracting
Contract Auditing includes
Who outlines the specific criteria for credentialing?
The State and NCQA- National Committee for Quality Assurance.
What are the 2 ways to access Mentor?
Through the MyApps, or Go/Mentor
Contracting documents
APEX or PAAG
How can providers access Humana's external resources? (what is the url for Humana's provider site?)
What happens during Humana Provider Onboarding?
The Market provides specific Humana information to guide the Provider on Humana's processes and Procedures
What are the different cycles within the credentialing process?
Initial, re-credentialing, and de-credentialing
How do you have to search for your DX code if its longer that 3 characters?
Add a decimal
Processed claim information
CAS- Claims Administrative System
What authorization type can providers use the Prior Authorization search tool for?
Outpatient- all Inpatient authorizations require prior authorization.
What does Onboarding usually consists of?
What could cause a Provider to lose their Credentialing status?
Malpractice, receiving clinical or financial sanctions and missing required re-credentialing information
How can you save an excel spreadsheet to your mentor favorites?
Search by name for the resource, select the I Want to drop down, select Save to Favorites, Choose/Create the Folder to save to.
Cases/Tasks from different Humana teams
CRM
What page has videos that provide insight into some of the most common policies and procedures related to claim submissions, coding authorizations, or referrals among others?
Making it Easier page, a tutorial library that remains up to date with the latest information and is available to assist providers in a more efficient way of claim submissions.
Who manages Humana Contracts after Provider Onboarding?
Network Operations Coordinators NOCs
Describe Delegated credentialing
When Humana accepts a provider's credentialing status from an external entity, Humana does not perform the credentialing review but deems the provider participating per the delegates verification of the Provider's credentials.
What kind of documents does Mentor House?
Policies, processes, procedures, and code information.
What is Humana Community Navigator? (Findhelp)
A single-resource platform that provides providers access to more than 500,000 social service programs across the United States for any patient no matter their insurance and at no additional cost.
What would require an amendment to a contract?
Once credentialing is complete- a Provider is considered BLANK and can receive payment for Humana members.
In-Network/ Participating
True/False: Mentor documents can be shared with providers.
False- Mentor documents are generally internal resources for Humana employees. An exception may be available if the resource specifies that is can be externally distributed.
Important Internal Humana resources, processes, spreadsheets etc.
Mentor
Why might a provider require access to the formulary on Humana's site?
A formulary is a carefully curated list of medications covered by Humana. Providers use this list to ensure that prescribed medications are covered by the patient’s plan, reducing out-of-pocket costs and avoiding delays in care.