Wiki Credentialing question

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sherylm1

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We have had some issues getting credentialed with Medicare. Our group effective date is 7/31/17, but our provider(we only have 1) is not assigned to the group effective until 10/1/17. Does anyone know of a way to get the claims from 7/31/17 to 9/30/17 processed without the providers name on the claim? My knowledge tells me there needs to be a rendering providers name on the claim, but I just would like to be sure before writing off these claims.

Thanks in advance!

-Sheryl M.
 
I do the credentialing here at our facility for 100+ providers. Unfortunately with Medicare there is no retro active coverage when a provider is being credentialed. So in your situation for example:

* Dr. Smith was credentialed on 10/01/17, but facility was credentialed on 07/01/17
* A claim for Dr. Smith was denied for date of service 09/15/17 as not a certified provider with Medicare
* There is no "work around" or trick that can get the claim paid as the information is valid and correct on the claim.
* Dr. Smith was the correct provider but was not eligible with Medicare until 10/01/17.

The account would be an adjustment/write off. It is a bummer and it is always good to check before taking a write off but in this case it would be the correct action.
 
Similiar situation

Is it legal or okay to bill a non contracted provider under another contracted provider to any insurance for the first 90 days of starting at a new clinic while waiting to be credentialed with the insurance companies? Where can I find the documentation to support this?
 
In general the answer is no. The exception to this is if the new provider is providing locum services (see CMS guidelines). Often times provider offices will try to use the Locum rule when it does not actually apply, which can open you to audits and revenue retractions if found out. You will need to make sure that the provider meets all of the requirements.

I know that it can be frustrating with new providers that they need to wait for the credentialing period to be completed. We try to reach out to the provider as soon as we know of the new employment to help reduce the waiting period. Options like PECOS for Medicare can help reduce the wait time.
 
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