AultCare is the first healthcare organization to earn CORE Recertification for three sets of CAQH CORE Operating Rules, demonstrating its ongoing commitment to streamlining eligibility and benefits, claim status and payment and remittance transactions. To ensure organizations continue to conform with operating rules as technology evolves, mergers and acquisitions occur and other market dynamics take place, CORE Recertification is now required every three years.

What is primary source verification of a healthcare provider? Why is it important? Primary source verification (PSV) is the process by which a health plan or hospital checks an individual provider’s reported credentials and qualifications. This crucial step not only protects the provider but also the hospital, health plan and—more importantly—the patient.

In a recent study, CAQH found that inefficient COB processes cost the healthcare industry more than $800 million annually. The bulk of these costs are incurred because health plans often do not have access to high-quality data about other overlapping coverage before claims are paid.A successful COB program increases efficiency, prevents incorrect payments, and provides a better experience for providers and members, but it requires trustworthy data about coverage overlaps. Many vendors claim to have this data, but the quality varies.

There are a lot of reasons to start a payment integrity program: potential cost savings, operational efficiency, a taste for innovation. For Chad Roswick, senior director of Enterprise Shared Services at L.A. Care, a health plan serving the most vulnerable residents of Los Angeles County, the reason was financial stewardship. The health plan has a large Medi-Cal membership, and Chad wanted to make sure that they were properly administering state and federal funds and reducing expenses when possible.

What Is a Provider Directory? Simply put, a provider directory is a list of physicians in an area and within an insurance plan. People use that information when they need care to find a local doctor that takes their insurance and is also accepting new patients, so the information needs to be accurate. Health plans also create directories to help members decide which insurance product to sign up for during open enrollment periods, so members can ensure that their preferred doctors accept the plan they choose.

What is provider credentialing or physician credentialing?Provider credentialing is a regulated process of assessing the qualifications of specific types of providers. This important safety check requires providers such as doctors, dentists, and other allied healthcare professionals to show they have the proper education, training and licenses to care for patients. Hospitals and health plans verify the information supplied by the provider before they are included as an in-network provider.

The term “coordination of benefits” pops up everywhere these days. But hearing it and knowing what it is are two different things. Read on for a little primer, so you can get up to speed on this essential topic of healthcare administration.  What is coordination of benefits? 

In February 2021, CAQH CORE launched a new CAQH CORE Participant Dashboard. This user-friendly platform will simplify how participants can engage with their current work groups and join new ones. It also includes a global calendar of all CAQH CORE events, and enables easy access to all work group documentation, rosters and meeting information. If you are a CAQH CORE participant and did not receive an email with information about how to register, please email core@caqh.org.  

The healthcare industry is facing unprecedented challenges. Medicaid plans, in particular, are navigating significant increases in enrollment and new strains on their time and resources. Your credentialing primary source verification process (PSV) shouldn’t add to your burden. VeriFide™ is seamlessly integrated into CAQH ProView, which is used by more than 1.6 million providers to exchange professional information with payers for commercial, Medicare and Medicaid programs.

This month, CAQH will be sharing tips, tools and resources to help Medicare, Medicaid and commercial plans improve the quality of provider directories.