Centene Credentialing Services for your Independent Practice

Centene is dedicated to assisting individuals in living better lifestyles. We provide high-quality care, innovative programmes, and a comprehensive variety of health solutions to support families and individuals in getting well, staying well, and being well.

Purpose

The credential validation program’s goal is to use reasonable care and consistent standards in the selection and retention of competent physicians as members of Carolina Complete Health’s system. The major goal of the credential verification programme is to ensure service accessibility and availability by successfully choosing and keeping participating suppliers. The credential confirmation program’s purpose is to ensure that Carolina Complete Health develops and retains a team of professional practitioners who are competent to meet the health care necessities of Carolina Complete Health’s covered benefactors in an efficient, complacent, safe, and intelligent manner by meeting the program’s main goal.

Our Specialist will assist you in being credentialed right away

During the credentialing process, we will examine your educational background, career experience, certifications, and registration to practice in a healthcare sector. We will track your progress throughout the credentialing process to determine your education, training, credentials, and registration to practice in a health care setting. We will check all of your documentation to guarantee that you are certified by one of the world’s most prestigious healthcare providers. We are committed to long-term growth as a team. We will assist you in receiving the services you require. This is how we express our gratitude to our clients and our commitment to providing exceptional customer service.

Procedure

Centene has set guidelines for handling practitioner selection and maintenance functions. These norms include practices for practitioner credentialing, re-credentialing, and continuous monitoring that meet the credentials of applicable state and federal regulatory requirements, applicable accrediting body standards, including the National Committee for Quality Assurance (NCQA), 42 C.F.R 438.214, and Carolina Complete Medical requirements to the extent that those norms do. This policy is consistent with the requirements outlined in Attachment M. Policy on Uniform Credentialing and Re-credentialing

Carolina Whole Health will provide the Credentialing and Re-credentialing Policy to the Team for processing and approval thirty (30) days following contract award for evaluation / confirmation. The Guidelines must be authorized by the Department at least sixty (60) days before contracts with providers are executed.

Carolina Complete Health will use the draught Policy supplied as part of the Proposal and Response prior to Department certification, notifying the provider that the Policy is subject to change based on Department evaluation and approval. Approved Provider Credentialing and Re-credentialing policies, along with all printed versions, will be made available on the Carolina Complete Care website, along with the effective dates of each policy.

Network Participation Committee:

Carolina Complete Health appoints a Provider Network Participation Committee to offer recommendations on credentialing issues through a peer-review procedure. This Committee determines Quality Decisions in accordance with the Credentialing and Re-credentialing Policy of Carolina Complete Health. The Chairman of the Provider Network Participation Member shall be the Chief Medical Officer (CMO) or a CMO designate. The chairperson must be a licensed physician in North Carolina.

Practitioner Categories:

The credentialing/re-credentialing programs based to, but are not limited to, the following practitioner categories:

• Medical doctors (MD)

• Nurse Practitioners (NP)

• Oral Surgeons (DDS/DMD)

• Chiropractors (DC)

• Osteopaths (DO)

• Podiatrists (DPM)

• Mid-Level Practitioners (non-physician).

When Carolina Complete Health does not pick or instruct its beneficiaries to see such a specific physician or group of professionals, as well as for non-participating practitioners, fulfillment of the credentialing/re-credentialing process is not necessary. This covers practitioners who only practice in a hospital environment or freestanding clinic and provide care for Carolina Complete Health beneficiaries as a result of them being referred to the hospital, inpatient setting, or freestanding facility. These professionals may specialize in, but are not confined to, the following fields:

• Anesthesiology

• Emergency medicine

• Neonatology

• Pathology

• Radiology

• Telemedicine.

Participation upon Completion of Credentialing

When the Medicaid Provider Registration Record (extended version) is ingested and a Medicaid/NCHC enrolled physician is active in the Medicaid system. Once the record has been parsed, it is put into the online profile, the help desk system, and the eligibility system for member cards and registration. When a practitioner joins a practice that is contracted to participate in Carolina Complete Health’s network, the practitioner’s involvement in Carolina Complete Health’s network becomes effective on the Medicaid/NCHC enrollment effective date. Time limits for loading credentialed professionals into the system(s): newly credentialed insurer attached to a contract renewal within ten (10) business days; newly credentialed provider connected to an existing contract within five (5) business days; alterations for a re-credentialed provider attached to an existing contract within five (5) business days after having completed re-credentialing.

Within ten (10) working days of successful completion credentialing, a newly accredited provider is affixed to a new contract; within fifteen (15) business days of completing credentialing, a newly credentialed hospital or institution is attached to a new contract; and within five (5) business days of completing credentialing, a newly credentialed provider is attached to an existing contract. Changes for a re-credentialed provider, hospital, or facility attached to an existing contract within five (5) business days of completion of re-credentialing. Changes in existing contract terms within ten (10) business days of the commencement after the change. Changes in practitioner service location, demographic data, or other information pertaining to Member access to services.  Payment should be paid on the next pay period following the above-mentioned condition.  A provider shall not be employed as a PCP or put into the provider database if the provider is unable to receive payment on Carolina Complete Health’s current payment cycle. Every day, the Department creates a provider file which includes all current and dismissed Medicaid providers. Carolina Complete Health is in charge of keeping the accurate provider identity card for claims and encounters data, as well as the service date.

Re-Credentialing

Practitioners are examined against objective quality standards based on re-credentialing materials given by the North Carolina Medicaid Department’s MMIS no less than every five (5) years during the Provider Credentialing Transition period. No less than every three (3) years following the Provider Credentialing Transition period.

Suspension of Payments During Re-Credentialing: Carolina Complete Health shall halt claims payment to any provider in its network for Dates of Services after the Department’s start date within one (1) business day of receipt of a notice from the Department that Provider payment has been suspended for failing to submit re-credentialing paperwork to the Department or otherwise failing to meet Department requisites. Carolina Complete Health will restart payment to the provider once the Department receives notification that the requested information has been received from the provider. If the provider fails to deliver the information within fifty (50) days of being suspended, the Department will terminate the provider’s Medicaid eligibility. Carolina Complete Health shall not be liable for any interest or penalties incurred as a result of payment suspension at the time of re-credentialing. Carolina Complete Health has handled payment suspension during network re-credentialing. Policy on Provider Credentialing and Re-credentialing

Centene Credentialing Phone number

Please call our third-party provider, The Call Number, at 800-367-5690 to verify employment and status of application.

Centene Enrollment Application

https://www.arkansastotalcare.com/content/dam/centene/artotalcare/pdfs/ARTC18-H-054_Credentialing%20Atypical%20Provider%20Application_v6.pdf
Apply here and fill it correctly: In this way they’ll verify all your details and on constant basis notify you about your o-going procedures and progress respectively. Here you’ll find enrollment form:

Centene Enrollment Email

You can also send email from this address. To obtain information and communicate directly with our officers, please send an email to mediainquiries@centene.com.