How State Medicaid Programs can Improve the Provider Enrollment Process

November 2016

Enrolling healthcare providers in state-operated Medicaid programs and Managed Care Organizations (MCOs) is a cumbersome and expensive manual process involving long lead times, billing and reimbursement issues, as well as significant data entry.

At a presentation for the Medicaid Enterprise Systems Conference, CAQH Director Ann Brisk discussed trends in Medicaid provider enrollment with Steven A. Smith and Dennis Elliot of TennCare, the Tennessee Medicaid program. Smith and Elliot shared the TennCare story of how they streamlined the enrollment and verification process to improve their bottom line.

In 2011, TennCare chose CAQH as its provider data partner and began using CAQH ProView to collect information for enrolling providers to accept Medicaid patients. TennCare is one of the first Medicaid programs to embrace an established national solution already in wide use by most commercial health plans. Prior to adopting this CAQH Solution®, TennCare was using paper applications to collect all provider information, which required manual entry into their Medicaid Management Information System. The state maintained a large filing system to manage thousands of applications. 

CAQH ProView has complete, up-to-date information available from providers delivering health and wellness services. For health plans, the solution reduces time and resources needed for credentialing, network directory maintenance and other administrative functions requiring provider data.

TennCare switched to CAQH ProView to take advantage of this proven electronic process to automate provider on-boarding and enrollment. It made sense to leverage the solution, considering many of the state’s Medicaid providers already had their self-reported information in the CAQH ProView system. More than 1.4 million physicians and other providers nationwide maintain a wide range of information within the system.

As a result, TennCare was able to re-engineer an inefficient and redundant provider data management process by using the solution to simplify the downstream Medicaid MCO credentialing process. Another benefit was improved data quality by shifting from a manual to an electronic process. TennCare also decided to take advantage of CAQH SanctionsTrack, which integrates within CAQH ProView. TennCare was able to prevent providers with disciplinary actions from becoming enrolled in Medicaid and significantly reduce the time it takes for providers to be approved.

CAQH ProView enabled TennCare to make it easier for providers to enroll and accept Medicaid patients and offer healthcare services to the citizens of Tennessee.

To learn more about CAQH Proview, visit www.caqhproview.org

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