Initial Credentialing  

The credentialing process starts with a new faculty recruit. When the department chairman extends a job offer, the following occurs:
   
1. Faculty Introduction Letter.

Faculty Introduction Letter details the process to obtain a Texas license, DEA, DPS and outlines expectations for incoming faculty. This letter is sent to the newly recruited faculty member by the department contact person and the department chairman. UTSHS Credentialing Department allows a practitioner 60 days (from the date the introduction letter is sent) to remit the reply form (Attachment 2) to UTSHS indicating that licensure applications have been completed and submitted to appropriate agencies. If the recruit has not submitted the licensure application within 60 days, the Vice President for Clinical Operations will contact the department Chairman regarding the practitioner's lack of response.
 
• Managed care payers will not accept practitioners without a Texas Medical License.

All out-of-state practitioners must sit for an examination in Austin to obtain a Texas medical license NO EXCEPTIONS!!!!

•The large managed care payers do not accept a faculty temporary license.

•The name on the TDI application must exactly match the name as it appears on the Texas State license for billing and reimbursement purposes.

2. New Faculty Credentialing Designation Form.
 
New Faculty Credentialing Designation Form is completed by the clinical chair indicating the desired campus privileges and credentialing for the new recruit.  It is essential for the clinical department to mail the introduction letter to the new faculty recruit. 

3. Next, departments must submit a Provider Request Form (PRF) to all persons indicated on page 1 of the(PRF).  This form allows you to indicate which parts of the process are needed for a practitioner. The information indicated on the PRF should match the Departmental Chairman's designation form.
The PRF is located at S:PUB\POLICIES\PROV_REQ_FORM

4. After the PRF is submitted, the appropriate packets will be hand delivered to the designated credentialing contact person in your clinical department.

The designated credentialing contact person in your clinical department will receive Billing Enrollment and Managed Care credentialing forms from UTSHS, and hospital privileging forms from Campus Wide Credentialing Service at Parkland.

Departments deliver packets to practitioners for completion. Practitioners complete and remit completed packets to the department.

UTSHS Credentialing suggests that packets be sent by overnight mail (Fed Ex, UPS, or USPS) to practitioners who are out of town, and hand deliver to practitioners on campus.

Departments should encourage recruits to complete the packets within 10 days and return according to packet instructions. If the practitioner delays completing this paperwork, it will result in a corresponding delay in getting that practitioner properly credentialed and enrolled with payors and prepared to bill for, and collect for their services.  If the UTSHS credentialing packets are not completed and returned within (30) days, the Vice President for Clinical Operations will notify the Department Chair that the new recruit has not responded.

5. Once the packets are returned to the departments a final check of the documents for completeness and accuracy should be completed. The department should also add data that the new practitioner lacks such as clinic phone numbers, fax numbers, etc.  The department should then alert the UTSHS Credentialing staff that the packet is ready. The UTSHS Credentialing courier will pick up packet from the department.

When hospital packets are returned to the clinical department, submit those packets to Campus Wide Credentialing.  These packets DO NOT go to the UTSHS Credentialing offices.

PLEASE DO NOT SUBMIT MANAGED CARE
CREDENTIALING & BILLING ENROLLMENT
DOCUMENTS TO CAMPUS WIDE
CREDENTIALING SERVICE AT PARKLAND.

6. Once the packets have been completed and returned, UTSHS begins the process of verifying the licenses, education and training of the practitioners. Other data such as malpractice history and actions taken by licensing boards are also verified and investigated. This process is performed according to NCQA and TDI standards.

Verification of certain practitioner data must be accomplished using specific criteria in order to be compliant with approved credentialing processes.  If the data is not timely verified, additional delays to the credentialing process may result.  This process can take 30-90 days depending on the complexity of the data and the number of data elements being verified and investigated.

7. After all data elements have been verified and all necessary office audits by UTSHS are completed, the practitioner file is presented to the UTSHS Credentialing Committee. The Committee meets on the first Monday of every month and is composed of UTSWMC faculty physicians. The committee reviews all practitioner credentialing profiles and votes on their credentialing status.

8. If approved by the Credentialing Committee, the Provider Relations group begins the process of preparing the practitioner information for submission to the Managed Care Organizations (MCOs). Provider Relations notifies the clinical department that a practitioner has been approved.  A profile is sent to the department for final review before it goes to the MCOs.

This "final" review allows the clinical department time to verify the following information with Provider Relations:

a. office location
b. phone and fax number
c. practitioner office hours.
d. confirm if practitioner is accepting new patients.
e. confirm current hospital privileges, etc.

The final review also ensures that the most up-to-date information is submitted to MCOs for their provider directories. Patients use this data to schedule appointments.

9. Provider Relations submits provider data to payers.
Payers review data before accepting providers for loading in the payer databases and claims adjudication systems. Most managed care payers do not require credentialing of mid levels if the mid levels bill "incident to" a physician. Managed care payers do require credentialing if a mid level bills as an independent practitioner.
 
Each clinical department should meet with Dieter Lehnortt (8-6108), Director of Billing Compliance, to discuss any and all mid level practitioners before submitting a PRF.

Be prepared to discuss with Billing Compliance and to submit to the payors, the following in regard to mid level practitioners:
•Written pathways and protocols outlining practice activities of the mid level
•Name of supervising physician
•Documentation outlining situations that trigger the referral of cases to the supervising physician by the mid level practitioner
•List of limitations of the mid levels practice

Questions concerning a practitioner's status with the MCO's should be directed to Provider Relations at the Managed Care Help Desk 214-645-0496. Provider Relations maintains a web-site titled the Managed Care Guidelines.  One of the many resources in the Managed Care Guidelines is the MCO Participation Roster. This indicates a practitioner's status with each managed care payer.This web-site may be accessed at S:PUB/POLICIES/MC_Guidelines