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 Hi page under HSS, or Go/Mentor
Contracting documents
APEX or PAAG
Define NOC
Network Operations Center
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
Define ASAM
American Society of Addiction Medicine
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
If I wanted to look for only Medicaid documents, what can I do to my search?
Filter your search using the Business Segment
Cases/Tasks from different Humana teams
CRM
Define SLA
Service Level Agreement
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.
Define JOC
Joint Operating Committee
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
How do you know if updates have been made to documents?
Check Alerts
Important Internal Humana resources, processes, spreadsheets etc.
Mentor
Define DMS
Department of Medicaid Services