User Guide — Credentialing Co-Sourced

 

As co-sourcing partners, we use the Provider Credentialing and Medical Group Credentialing pages so that your practice can tell us specifically what enrollment work athenahealth needs to do on your behalf.

 

A credentialing status indicates a provider's contractual relationship with a payer. This status determines payer network privileges, reimbursement rates, and provider enrollment requirements. Credentialing statuses in athenaOne are:

• Participating — The provider is contracted with the payer or is part of a group that is contracted with the payer.
• Not Participating — The provider is contracted with the payer, but at lower, out-of-network rates than providers with the credentialing status of "Participating."
• In Progress — Hold Claims — The provider is in the process of contracting with the payer. Hold claims until a specified date.
• In Progress — Send Claims Non-Participating — The provider is in the process of contracting with the payer. Send claims as Not Participating (non-par) until a specified date.

 

Your practice may need our legal business information to complete Credentialing forms for a payer when you establish a new credentialing relationship between the payer and a provider or group.

 

Legal Business Name: ATHENAHEALTH INC & SUBSIDIARIES

Tax ID Number: 043387530

Address: 80 Guest Street, Boston, MA 02135

Phone: 617-402-1000

Fax: 888-864-4428

Email: enrollmentservices@athenahealth.com

 

Note: If your practice receives enrollment paperwork directly from a payer, please notify the CSC by selecting Support > Create Case or Call in the Main Menu. Enrollment forms should be coming directly from athenahealth through the Enrollment Worklist.

 

 

You complete credentialing forms to begin a new relationship with a payer, in order to become Par with them (also known as In Network). After you establish the initial relationship with the payer, athenahealth completes enrollment forms (on your behalf) to enroll in or make changes to additional services with the payer, such as EDI, EFT, ERA, Eligibility Checking, getting your Physical and Pay-to address updated, etc.

 

 

If your practice is still in the onboarding process, setting up credentialing defaults is an efficient way to provide us with the initial information we need to know about your payer/provider contractual relationships, so that we know what enrollment work we need to do on your behalf. Your Project Manager can help you with this process.

 

 

To add a provider to a federally qualified health center (FQHC), open a case to enroll the provider in the Uniform Data System (UDS). UDS is a reporting requirement for Health Resources and Service Administration (HRSA) grantees. When you open the case, please specify that you need to enroll a new provider in UDS Quality Management measures for an FQHC practice.

Note: Before providers can be created, the Medical Groups table must be complete.

 

When you add a new provider to athenaOne, you must enter the provider's credentialing status for each payer that is already set up for your practice. The easiest way to perform this task is from the Providers page.

• When you use the Billing Provider Guided Setup on the Providers page, the Provider Credentialing page appears automatically during the Credentialing step.
• When you configure a provider manually on the Providers page, you can enter the provider's demographic information and then click Save and Update Credentialing. The Provider Credentialing page appears.

On the Provider Credentialing page, you can enter credentialing statuses for the new provider.

 

Note: On the Providers page, providers without a credentialing status selected appear highlighted in yellow. You can select a credentialing status from the Provider Credentialing page.

 

 

If your practice bills as a group, set up your medical group credentialing statuses using the Medical Group Credentialing page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Credentialing, click Medical Group Credentialing.

 

 

You need to enter credentialing statuses in athenaOne in these situations:

• During your initial setup on athenaOne, as part of onboarding.
• When you add a new provider to athenaOne.
• When a credentialing status changes.
• When you enter a claim for a new payer for a given provider or group. A new payer is any payer that does not have a credentialing status established in athenaOne.