December 21, 2016

What is CAQH?
CAQH (Council for Affordable Quality Healthcare) is a non-profit organization, set up in the year 2000, for the purpose of bringing together health plans, healthcare providers and trade associations. Its primary goal is to make high-quality healthcare easily accessible to patients and to reduce the stress associated with healthcare administration.

CAQH has several initiatives geared towards simplifying the paperwork associated with healthcare administration. These initiatives go by the names CAQH CORE, CAQH Solutions and CAQH Explorations, which in turn have sub-ventures. All these initiatives have different focuses and functionalities.

Why should we care about CAQH?
CAQH Solutions encompasses CAQH ProView, previously known as Universal Provider Datasource (UPD), which is a medium where healthcare providers self-report their professional and demographic information. This information is stored securely and confidentially on the database. The fact that this is a universal database is why CAQH is so important. Providers need to fill out credentialing data only once, rather than separately for multiple insurance providers. In fact, relying on the authenticity of the database, a large majority of the national health insurance companies now REQUIRE providers file a CAQH application before taking on the process of credentialing or re-credentialing them.

Insurance companies use the CAQH website as a tool for credentialing and contracting services. Once the provider makes application to a particular insurance company, the provider’s information is then made available to the insurance company, who then is authorized to utilize it for credentialing, maintaining networks and directories of providers, claim settlements, etc. In this way CAQH ProView is dedicated to minimizing the time, costs, resources, errors and inefficiencies associated with healthcare administration. If CAQH is completed incorrectly, payments would be submitted to the wrong address or wrong TIN. Incorrect information also affects insurance directories, inevitably affecting your patient volume. If Credentialing Documentation is not correctly provided, payers will directly inquire with your office by phone, fax, or mail, delaying the credentialing process by an additional 45-60 days.

On average a CAQH Application takes from 1-4 hours to complete, requires daily updates for documentation requests, releases, expirables, etc. Our staff is specifically trained to understand the finite requirements from all payers on a national level, allowing us to properly complete your CAQH application, and thus saving you TIME and MONEY!

What does the CAQH application process look like?
The first step is to get a CAQH ID, which could take anywhere from a few days to a few weeks. Once you have obtained it, you will set up a username and password. Thereafter, you will be required to complete the online application and submit the required documents. The list of documents required depends on the kind of healthcare service you provide. Once you have completed the form and have all the documents in place, you will have to sign and attest the application. Once your application has been certified, you will have to grant access to your professional and demographic information on the database to the insurance companies. This marks the beginning of your credentialing and contracting process with the insurance companies.

Which payers use CAQH?
All commercial insurance providers, as well as Medicare and Medicaid plans use CAQH. Even commercial payers who ask a state application can accept a State Duplicate Application from CAQH. This saves your credentialer 3+ hours of completing a duplicate state application that looks much like the traditional CAQH Application.

When should providers update their CAQH profile?
Even when there are no modifications in the provider profile, their CAQH profile needs to be re-attested every 120 days. Anytime a Medical License, DEA, Malpractice, Board or practice location is changed you must log into CAQH and update and re-attest the data. When a provider changes his/her practice, or incurs any other modifications in the profile, it must be updated on the CAQH database. In such a situation, the provider will have to log in to their CAQH account, update their profile and re-attest the information. CMS is now requiring all payers to audit provider practice details, if a provider practice address is incorrect and it is reported to CMS the payer faces a heavy penalty. Payers now utilize CAQH, Availity, Navinet and several other websites to review provider directories. If the provider fails to clarify and update information the payer can suspend participation or terminate a provider. Did you know that some states actually check CAQH for CMES completed and you MUST list all CMES to date and attach proof of completion? Our staff understands the unique requirements of Credentialing as a whole and lends this knowledge for a LOW MONTHLY FEE.

What if the provider’s data on the CAQH database is incorrect?
If the CAQH application is done wrong, provider online directories will display incorrect data. Patients who access this data will be misled or confused, and will find another provider to see. Contracts are not loaded by the payer until the provider is credentialed. Thus, if the credentialing process is delayed by missing or incorrect information (4-6 weeks being the usual time frame), the provider will not be able to participate in the network of the insurance company. Out-of-network providers are a thing of the past, leading to little or no interest from prospective patients as well. Thus, it triggers a chain reaction that follows the provider for a long time, because even if the incorrect information is removed or rectified, it never completely disappears. It eventually leads to delayed or lost payments for the providers. The payer will send 3 notices via email, then a fax, and subsequently by mail. If a provider fails to respond because of incorrect address, or contact information on CAQH, the providers will not find out until a patient claim is denied, or a patient calls their provider to tell them they were told to choose another physician. Once you are terminated for failure to respond to a re-credentialing request this is a negative, and the NPDB may be informed and all future credentialing disclosure questions will need to be answered to the affirmative, with a lengthy explanation as to why the provider failed to re-credential.

How much does it cost?
The CAQH application process is free of charge. However, it is extremely time consuming and can be very frustrating to most people, and can be difficult to complete correctly in a timely manner. Having a professional complete this task for you is the obvious answer.

What do I do if I am unable to complete the CAQH application myself?
You might have gathered by now that the CAQH application is crucial to being credentialed, and an essential step to participate with insurance companies. You might also have realized that the CAQH application can be a daunting task for many. However, there is a solution. You can contact a good credentialing services firm who can do all this for you, and in a much shorter time frame than most.

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