Contracting
Define 'Provider Network'
A network is a group of providers that mutually contract with insurance carriers or employers to provide healthcare services to participants in a specified managed care plan.
Define 'Credentialing'
Credentialing is the process of verifying and evaluating a provider’s qualifications, including education, training, experience, and professional licensure, to ensure they meet the standards required to deliver care within a network.
What are the 2 ways to access Mentor?
Through the MyApps, or Go/Mentor
What system is used for claims processing?
CAS
What is the web address for Humana’s provider website where external resources can be accessed?
What contractual document provides detailed information about providers within a group?
A roster is utilized to capture detailed information about providers within a group. This data is used by loaders to ensure the accurate display of providers in the Provider Directory.
How often do providers normally have to complete the recredentialing process?
Every 3 years.
How do you have to search for your DX code if its longer that 3 characters?
Add a decimal
Define MCO
Managed Care Organization. An MCO is an entity that provides or arranges managed healthcare services to enrolled members, often under a contract with government programs (such as Medicaid or Medicare) or private insurers.
Which types of authorizations can providers search for using the Prior Authorization tool?
Outpatient- all Inpatient authorizations require prior authorization.
Name 3 elements included within Humana's Provider Contract.
A contract contains comprehensive details such as:
Legal Name
Do-Business-As (DBA) Name
Tax ID
NPI
Specialty
Address
Contractor
Signature page
Product Participation Page (LOB)
Physician Reimbursement (per LOB)
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.
What are the 7 Steps to the Provider Experience?
Contracting Priorities, Provider Contracted, Data Load, Provider Alignment, Claims Submitted, Claims Processed, Explanation of Remittance.
Which page contains videos that explain common policies and procedures, such as claim submissions, coding authorizations, and referrals?
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.
What issues may arise if a provider's contract isn't complete/active?
Claims may be denied or delayed
Members may experience delays in care
Increased volume of disputes/compliants
Fill in the blank: Credentialing confirms that the applicant is clear of ___ by federal, state and local authorities.
BONUS- Define the missing term for an extra $100.
Sanctions;
Sanctions are disciplinary actions or penalties imposed when an individual, provider, or entity fails to comply with established policies, procedures, or legal requirements.
What kind of documents does Mentor House?
Policies, processes, procedures, and code information.
Where can you find a library of tutorials and tip sheets designed to make it easier for providers to do business with Humana?
Making it Easier, go/makingiteasier
Explain what the Humana Community Navigator (Findhelp) is and what services it provides?
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's the focus of contracting?
Humana's contracts focus on financial and service delivery arrangements.
What is the main purpose of credentialing?
Credentialing emphasizes the provider's qualifications and adherence to standards.
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.
What is the difference between Par and Non-Par Providers?
Participating, Non-Participating.
Participating (PAR) Providers:
These are healthcare providers who have signed a contract with a health insurance plan to provide services to members at agreed-upon rates. PAR providers typically:
Non-Participating (Non-PAR) Providers:
These providers do not have a contract with the insurance plan. Non-PAR providers:
What is the formulary on Humana's site used for?
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.