Section_15_Provider_Enrollment_and_Management_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Provider Enrollment and Management (Section 15)

Central Bill Process

Provider Enrollment and Management (PWS Section 15) Requirements Specifications Document

(LEGACY DRAFT)

Prepared for:

U.S. Department of Labor Office of Worker’s Compensation Programs

Revision History:

SPECIAL NOTICE: This document is a legacy draft requirements specification document developed between 2011 and 2012. As outlined in the Performance Work Statement, the Contractor will be required to review this RSD and make appropriate updates wherever necessary. (Please refer to PWS R0052 for more details.)

Table of Contents Provider Enrollment and Management - DFEC

71.1 Provider Enrollment and Management Overview - DFEC

71.2 Provider Enrollment and Management Business Process Description - DFEC

71.2.1 Provider Enrollment Process

71.2.1.1 Provider Enrollment Methods

71.2.1.1.1 Hardcopy Enrollment

81.2.1.1.2 Online Enrollment

81.2.1.1.3 Faxed Enrollment

81.2.1.2 Provider Enrollment Qualifications

91.2.1.2.1 Inpatient/Acute Care Hospitals

91.2.1.2.2 DME Providers

91.2.1.2.3 State Licensure

91.2.1.2.4 Other Provider Licensure Exceptions/Considerations

91.2.1.2.4.1 DME Provider

101.2.1.2.4.2 MRI Facilities

101.2.1.2.4.3 Ambulance/Fire Department

101.2.1.2.4.4 Providers in states that do not require a license

101.2.1.2.4.5 License Renewal and Expiration

111.2.1.2.4.6 HHS Excluded Provider File

111.2.1.3 EFT and EDI Enrollment

111.2.1.3.1 EFT Enrollment

111.2.1.3.2 EDI Enrollment

121.2.1.4 Provider Activation and Deactivation

121.2.1.4.1 Provider File Management

121.2.1.4.2 Provider File Maintenance

131.2.1.4.2.1 Provider Change of Practice Name or Provider Identifier

131.2.1.4.2.2 Provider Change of Address (COA)

131.2.1.4.2.3 Provider Change of EFT/ACH Information

131.2.1.4.3 Paper File Maintenance

141.2.1.5 Provider Outreach and Communications

141.2.1.5.1 Provider Outreach and Communication Program

151.2.1.5.2 CBP Portal

151.2.1.5.3 CBP Call Center

151.2.1.5.4 Provider Training

161.3 Provider Enrollment & Management Business Process Flow - DFEC

161.3.1 Provider Enrollment Through Paper

171.3.2 Provider Enrollment Through the CBP Portal

181.3.3 Express Enrollment - DFEC

191.3.4 Provider Maintenance

Provider Enrollment and Management - DEEOIC

202.1 Provider Enrollment and Management Overview – DEEOIC

202.2 Provider Enrollment and Management Business Process Description - DEEOIC

202.2.1

202.2.1.1

202.2.1.1.1

212.2.1.1.2

212.2.1.1.3

212.2.1.2

212.2.1.2.1

212.2.1.2.2

222.2.1.2.3

222.2.1.2.4

222.2.1.2.4.1

222.2.1.2.4.2

222.2.1.2.4.3

232.2.1.2.4.4

232.2.1.2.4.5

232.2.1.2.4.6

242.2.1.2.4.7 Multiple Licenses

242.2.1.2.5 District Medical Consultant (DMC) Providers

242.2.1.3

242.2.1.3.1

242.2.1.3.2

242.2.1.4

252.2.1.4.1

252.2.1.4.2

262.2.1.4.2.1

262.2.1.4.2.2

262.2.1.4.2.3

262.2.1.4.3

262.2.1.5

272.2.1.5.1

272.2.1.5.2

272.2.1.5.3

272.2.1.5.4

292.3 Provider Enrollment & Management Business Process Flow - DEEOIC

292.3.1

302.3.2

312.3.3 Express Enrollment - DEEOIC

322.3.4

Provider Enrollment and Management – DCMWC

333.1 Provider Enrollment and Management Overview – DCMWC

333.2 Provider Enrollment and Management Business Process Description - DCMWC

333.2.1

333.2.1.1

333.2.1.1.1

343.2.1.1.2

343.2.1.1.3

343.2.1.2

343.2.1.2.1

353.2.1.2.2

353.2.1.2.3

353.2.1.2.4

353.2.1.2.4.1

353.2.1.2.4.2

363.2.1.2.4.3

363.2.1.2.4.4

363.2.1.2.4.5

363.2.1.2.4.6

373.2.1.2.4.7 Multiple Licenses

373.2.1.3

373.2.1.3.1

373.2.1.3.2

373.2.1.4

383.2.1.4.1

383.2.1.4.2

393.2.1.4.2.1

393.2.1.4.2.2

393.2.1.4.2.3

393.2.1.4.3

393.2.1.5

403.2.1.5.1

403.2.1.5.2

403.2.1.5.3

403.2.1.5.4

423.3 Provider Enrollment & Management Business Process Flow - DCMWC

423.3.1

433.3.2

443.3.3 Express Enrollment - DCMWC

453.3.4

Provider Enrollment and Management Functional Business Requirements

464.1 Functional Requirements

524.2 Business Rules

Provider Enrollment & Management Supporting Functional Components

775.1 Initial Data Migration

775.2 Interfaces

785.3 Reports

805.4 Letters

Constraints

846.1 Assumptions

846.2 Dependencies

846.3 Issues/Open Items

Appendices

857.1 Terms & Definitions

1 Provider Enrollment and Management - DFEC

1.1 Provider Enrollment and Management Overview - DFEC

The CBP Provider Enrollment and Management solution will support maintenance of the provider file, provider enrollment processing, provider number assignment, and the provider outreach program to communicate program information, recommendations and updates to the provider and claimant communities. The Provider Enrollment and Management, and Provider Outreach functions will rely on the CBP Portal as the vehicle for providers to enroll, submit provider updates, and obtain program information.

1.2 Provider Enrollment and Management Business Process Description - DFEC The Provider Enrollment and Management component of the CBP program will support the enrollment of providers who complete the provider enrollment form successfully and can offer validation of their stated status; the efficient maintenance and management of the provider file in the medical bill process; and the outreach and communication with the provider community about program objectives and updates, DOL initiatives, and assistance with all elements of the CBP program.

1.2.1 Provider Enrollment Process

Current providers will have their provider numbers transferred to the new CBP system, and may continue to use their existing provider number for billing. New providers or providers whose previous numbers have been deactivated, with the exception of providers that have been excluded from the program, will be required to apply for a provider number by completing and submitting a provider enrollment form, either hardcopy or electronically through the CBP Portal.

1.2.1.1 Provider Enrollment Methods

Providers may submit hardcopy enrollment applications that can be downloaded from the CBP Portal, or mailed directly to the provider by a Call Center representative, upon request. Providers may also submit an enrollment application online by accessing the public CBP Portal and stepping through each required field.

1.2.1.1.1 Hardcopy Enrollment

Hardcopy enrollment forms and attachments are received at the Central Mailroom, These documents will be scanned and forwarded directly to the Provider Enrollment Unit through the workflow (details of which will be provided in the training materials) for screening of the entire enrollment form to ensure all pertinent information is present (signatures, addresses, names, licenses/certifications, and other information). If required data is missing, the Contractor will prepare the RTP form to be submitted back to the provider indicating which information is missing from the enrollment submission. If the enrollment submission contains all the necessary information, the representative performs provider credential verification. If the representative is able to validate the provider’s license/credentials, the enrollment completes processing through the medical bill processing engine, and a provider number is assigned. The provider number, CBP Portal login credentials, and welcome package are sent to the provider via email or hardcopy.

1.2.1.1.2 Online Enrollment

Online enrollment applications will be entered into the CBP Portal by the provider. The submitted data is processed through the medical bill process engine, and if up-front data validity edits identify missing or invalid data, the provider receives a real-time message via the Portal indicating that information is missing or invalid. If the enrollment data passes the up-front edits, the data is transferred by the workflow to a Provider Enrollment representative to perform provider credential verification. If the provider passes the credential verification, the enrollment completes processing through the medical bill process engine, and a provider number is assigned. The provider number, CBP Portal login credentials, and welcome package are sent to the provider via email or hardcopy.

1.2.1.1.3 Faxed Enrollment

“Express” provider enrollment forms will be initiated by DOL on behalf of DFEC Contract Nurses (CNs) and Vocational Rehabilitation (Voc Rehab) Counselors, or on a case-by-case basis as determined by DOL. Enrollments for CNs and Voc Rehab Counselors will be completed during training sessions coordinated by DOL. The provider information on the enrollments will be reviewed and validated by the DOL staff, and the enrollments will be faxed in batches to a dedicated fax machine at the Central Mailroom. These express enrollments will be clearly identified by a cover sheet that has been signed by a DOL training representative. Since the enrollment forms will be already verified by DOL, the Mailroom staff will perform only a cursory review of the forms prior to scanning and data entry. If any of the data validity checks identify missing or invalid data, the Mailroom staff or Provider Enrollment staff will contact DOL immediately to try to resolve the issue, in the interest of supporting an expedited enrollment. After an enrollment is successfully processed, the Provider Enrollment staff will fax provider numbers and login credentials on individual cover sheets back to the DOL representatives. The provider number and login credentials must be processed and sent to DOL for the CNs and Voc Rehab Counselors within 2 days.

This faxed enrollment process is the ONLY acceptable form of enrollment for Contract Nurses and Rehab Counselors. These contractors must have District Office approval for enrollment and cannot enroll on their own via the web. Although express enrollments are typically processed during DFEC Voc Rehab and CN training sessions through a group submission, often Voc Rehab Specialists or Staff Nurses will fax an enrollment directly to the dedicated fax machine for expedited enrollment on behalf of Voc Rehab Counselors or Contract Nurses. Once the provider number and login credentials are assigned, the Contractor will send this information directly to the Voc Rehab Counselor, Contract Nurse or other express-enrolled provider, not to the Staff Nurse or Voc Rehab Specialist.

Faxed enrollments may or may not always be “express enrollments” as defined above. Enrollments may arrive via fax, email, or mail for other provider types, and require expedited processing as requested by DOL.

1.2.1.2 Provider Enrollment Qualifications

The CBP Provider Enrollment Team is responsible for verifying and validating certain provider credentials before a provider is certified to participate in the CBP program. The Provider Enrollment representatives will work closely with providers who do not initially submit the proper documentation in order to facilitate an expeditious enrollment. If a provider fails to provide the required credentials and cannot be reached within a reasonable amount of time, the enrollment will be returned as RTP.

1.2.1.2.1 Inpatient/Acute Care Hospitals

The Contractor will review the enrollment application for providers enrolling as inpatient/acute care hospitals (provider type 01) to see if a Medicare letter has been included. If a Medicare letter is not included, the Contractor will validate the provider’s Medicare certification by checking against State and CMS data (the American Hospital Directory or the National Plan and Provider Enumeration System [NPPES] websites), the CMS excluded provider file, and provider-supplied information.

1.2.1.2.2 DME Providers

The Contractor will validate that providers enrolling as Durable Medical Equipment (DME) providers (provider type 75) have posted the required bond by checking the DMEPOS file supplied by Medicare. If the provider has not registered with Medicare, the Contractor will conduct provider outreach notification.

The Contractor will receive the DMEPOS file from CMS of all DME providers registered to provide and disburse DME equipment, supplies and devices. Any providers enrolling as type 75 will be verified against the DMEPOS file. If there are DME providers currently enrolled and not found on the CMS DME Provider file, the Contractor will conduct provider outreach to confirm the provider’s status.

1.2.1.2.3 State Licensure

Providers who enroll in the CBP will be required to provide their license information on the enrollment form, and to submit proof of state licensure according to their provider type (DO Express Enrollments--Voc Rehab/Contract Nurse/Other--are excluded from this requirement.). The Provider Enrollment team will review the submitted documents to establish if a license copy is present for all provider types on the application. If a license is attached, the representative will verify the information using State Licensure websites. If a license copy is not attached, or the license number is handwritten, the representative will return the enrollment application to the provider with an explanation of what is required.

For group providers, individual license copies for each provider in the practice, up to nine (9) licenses, must be submitted and individually verified. For groups of over 9 providers, the group license is validated, but the group practice is responsible for verifying the licensure of the individual providers.

In all cases, if a license cannot be sufficiently verified after 2 attempts within 2 business days by the Provider Enrollment team, the enrollment package will not be processed, and will be returned to the provider with an explicit explanation of what is needed in order to fulfill the enrollment application requirements.

1.2.1.2.4 Other Provider Licensure Exceptions/Considerations

1.2.1.2.4.1 DME Provider

The Contractor will receive the DMEPOS file from CMS on a frequency to be determined, containing all DME providers that are registered and bonded by CMS as a DME Provider. The Contractor will apply those providers to the CBP Provider file as (Provider Type 75). The DMEPOS File will be provided to the contractor directly from CMS.

Additionally, if any of these providers are excluded for any reason, CMS would disseminate that information to HHS, who would in turn send OWCP the excluded file. OWCP will provide the Contractor with the exclusions, and the Contractor will follow their processes for updating their provider file accordingly.

1.2.1.2.4.2 MRI Facilities

Certifications or proof of inspection certificates are acceptable documents for freestanding MRI facilities without a license.

1.2.1.2.4.3 Ambulance/Fire Department

Certifications or a paramedic’s license(s) are acceptable documents for verifying an Ambulance/Fire Department without a license.

1.2.1.2.4.4 Providers in states that do not require a license

A license to treat patients and provide medical care is required from any provider, regardless of whether it is restricted to one state, or if the provider possesses a full unrestricted license allowing him to provide medical services in other states based on his/her specialty. However, the Center for Complementary and Alternative Medicine (CAM) which includes practitioners of Acupuncture (only 42 states require licensure/certification); Chiropractic (all 50 states require licensure/certification); Massage Therapy (only 43 states require licensure/certification); Homeopathy (only 3 states require licensure/certification) etc., may not require licensure or certifications in some states. If the CBP Provider enrollment unit receives a provider enrollment application that indicates that their state does not require a license or certification, the provider must provide an official letter from the state stating that the specific state does not require a certification or license in the Medical Specialty for which the provider is trying to enroll. Additionally, the provider must also submit documentation and a certificate of completion showing that he/she has completed a course in the study of the CAM along with the number of Continued Educational Units (CEU’s) received.

1.2.1.2.4.5 License Renewal and Expiration

The provider file in medical bill process will store license expiration dates, and will contain a mechanism for flagging providers with licenses that will expire in 60 days and 30 days. The Provider Enrollment Team is responsible for sending letters notifying providers whose licenses are scheduled to expire in 60 days, and 30 days. The letter sent to providers whose licenses are scheduled to expire in 30 days will also provide a notification that payments will cease 31 days after license expiration. Information about license expiration will be available to all providers through the CBP Portal. However, the Provider Enrollment team will make every effort to conduct outreach with providers in order to obtain proper license renewal documentation.

The Contractor will accept and process provider license renewals within 60 days from initial notification of license expiration. If a provider’s license expiration is within 30 days of the processing date of a submitted claim, and the bill is in suspense, the Contractor will process the bill and notify the provider via adjudication of the bill (via the RV) that the provider license will be expiring within 30 days.

If the license expiration date of a submitted license copy is within 30 days of the enrollment processing date, the enrollment documents will be returned as RTP, and the provider will be advised to submit an updated license copy. If the Provider Enrollment representative can locate a license for the following year on the State Licensure website, it is acceptable to use the current license (as it is possible the provider may not have received the new license yet). Otherwise, the provider must submit another license with a new expiration date before the current license expires. The Provider Enrollment Team will verify the license with the state of licensure when a new expiration date is provided.

The medical bill process will automatically deactivate a provider 31 days after the expiration date on file if updated license information is not submitted, and will modify the provider status to reflect license expiration.

1.2.1.2.4.6 HHS Excluded Provider File

The Contractor will check each provider’s status against the current HHS Excluded Provider File prior to completing enrollment processing. If a provider is on the Excluded list, the provider will not be enrolled in any OWCP programs, and will be notified as such. Additionally, the Contractor will notify all claimants under that provider’s care. The Contractor maintains updates to the HHS Excluded Provider File as supplied by DOL.

If a provider becomes re-eligible after being excluded, the provider must submit a new enrollment form for complete processing through the cycle, along with an official reinstatement notification.

1.2.1.3 EFT and EDI Enrollment

As part of the CBP provider enrollment process, the Contractor will provide information about enrolling in EFT (mandatory) and EDI as a way of expediting and managing their bill processing and payments more efficiently.

1.2.1.3.1 EFT Enrollment

The Contractor’s provider enrollment process will identify providers who can receive payment via Electronic Funds Transfer (EFT). For new providers, EFT enrollment is required by DOL based on U.S. Treasury mandates. New providers who submit an enrollment to the CBP program must complete an EFT form.

The Provider Enrollment team is responsible for verifying the financial information provided on the EFT enrollment form before facilitating the completion of the EFT enrollment. Providers may sign up for more than one EFT account, which will have its own date span and status indicator in medical bill process. The Contractor also will update the medical bill process with EFT notification of change information received by the U.S. Treasury, via DOL, and will retain both the old and new EFT information on file. The Contractor will promote EFT enrollment through its Provider Outreach campaign.

1.2.1.3.2 EDI Enrollment

The Contractor will strongly encourage CBP providers to submit bills electronically through participation with Electronic Data Interchange (EDI) services as defined by DOL. The Contractor’s EDI campaign initiated by the Provider Outreach Program and offered through the provider enrollment process will supply the necessary guidance to providers on how to enroll into the service, or will provide their EDI information if they already have e-Bill Submit capability.

1.2.1.4 Provider Activation and Deactivation

New providers will be activated in the CBP program within 5 days after submission of enrollment forms that have been successfully processed. The Contractor will maintain provider records that show the following data elements, at a minimum:

· All provider identifying information

· The program(s) in which the providers participate

· Unique provider identifiers showing status (enrollment/active/exclusion/on review, etc.)

· Other provider classifications

· Provider type

· Locations

· Group affiliations

The Contractor will automatically deactivate providers who appear on the HHS Excluded File, which will reflect current updates in medical bill process, and will be matched against the current provider file; providers who have gone two (2) years without activity since their last bill submission; providers whose licenses have expired, and manually, on a case-by-case basis, upon DOL direction. Deactivation of Contract Nurses and Voc Rehab Counselors will be initiated by District Office staff (Staff Nurse or Rehab Specialist).

Bills received from an inactive provider will be returned as RTP from the Mailroom if the date of service is after the effective deactivation date. Bills or adjustments from an inactive provider will be processed if the date of service is before the effective deactivation date. Bills or adjustments from excluded providers will always be returned as RTP regardless of the date of service.

Any bills processed against providers who were deactivated due to exclusion while the bill was already in process, will post the corresponding edit indicating the provider is deactivated due to exclusion, and will be denied, regardless of the date of service of the bill. For any provider that has been deactivated due to any reason other than exclusion, an effective date of deactivation should be applied to continue bill processing and adjustment processing for dates of service that fall prior to the effective deactivation date.

1.2.1.4.1 Provider File Management

Maintaining up-to-date provider files is critical for the accurate processing of bills and authorizations, as well as for the integrity of the provider file. The Contractor’s provider management processes will accommodate the prompt update of provider files, and the efficient maintenance of all paper files.

The Contractor will track and log all maintenance activities using the date/time stamp of when the update or inquiry occurred, and who performed the update or inquiry. Queries for these updates will be accessible through the search functionality built into the CBP Portal, and can be sorted according to specialty, address, name, and ZIP code.

1.2.1.4.2 Provider File Maintenance

The Contractor’s medical bill process will support provider file records that contain all available provider information including:

· Provider numbers, NPI, Medicare, etc.

· Owners

· Affiliations

· Locations

· Specialties

· Taxonomy

· Category of Service (COS) mapped to Provider Type

· Addresses - The medical bill process will support provider record indicators for multiple provider addresses for each individual provider record, to include the primary office location, pay-to address, and Remittance Voucher (RV) address

· Contacts

· Licenses – The medical bill process will track an unlimited number of provider licenses for any number of states for any given provider. Each license entry on the provider record will have an effective “from” and “to” date range, allowing for accurate tracking and application of provider licensure data.

· IRS Levy status – DOL will provide the Contractor with the IRS levy and “Release of Levy” files as needed, and the Contractor will update the provider file in medical bill process accordingly so payments can be redirected accordingly. the Contractor will maintain current EFT information for the IRS so that monies and RVs can be routed appropriately to the different IRS locations, as well as to the provider. For IRS providers (type 98) that do not have EFT currently, the Contractor will perform outreach to obtain information in order to set up IRS providers with EFT. The CBP provider file currently has approximately 230 IRS providers with contact information available to perform outreach.

1.2.1.4.2.1 Provider Change of Practice Name or Provider Identifier

Providers requiring a change in practice name or one of their identifiers (i.e.., Tax ID number), must complete and submit a provider enrollment form, either hardcopy or online through the CBP Portal. The provider indicates “Update” on the form, and the form is processed through the same steps as if it were a new provider enrollment form.

1.2.1.4.2.2 Provider Change of Address (COA)

Providers requiring a change of address must complete and submit a Change of Address form, or provide information on facility letterhead. The Change of Address form can be obtained from the CBP Portal. After the form or letter is received and scanned in the Central Mailroom, the Provider Enrollment team contacts the provider to verify the address information before facilitating processing completion.

1.2.1.4.2.3 Provider Change of EFT/ACH Information

Providers requiring a change of EFT or ACH information must complete and submit an EFT form. The EFT form can be obtained from the CBP Portal. After the form is received and scanned in the Central Mailroom, the Provider Enrollment team contacts the provider and the financial institution to verify the EFT information before facilitating processing completion.

1.2.1.4.3 Paper File Maintenance

The Contractor will maintain updated paper provider files organized to support retrieval using the provider number. Paper files will be maintained for a period of 90 days after imaging for the DFEC, DEEOIC and DCMWC programs.

1.2.1.5 Provider Outreach and Communications

The Contractor will establish a relationship with the provider community through the Provider Outreach, Communication, and Training programs, each of which will rely on the CBP Portal, Provider Enrollment and Training teams, and the Call Center as the vehicles for assisting providers in experiencing a transparent conversion to a new CBP system, readily addressing enrollment, billing and other operational issues, and providing timely education on new or revised CBP program processes and policies.

1.2.1.5.1 Provider Outreach and Communication Program

The Contractor’s Provider Outreach program will be supported by the Provider Enrollment team with the following objectives:

· Address the outreach approach according to two program phases, Transition to Operations, and Ongoing Operations

· Introduce the fundamentals of the Contractor’s bill processing solution, and what changes can be expected

· Educate providers and claimants about the new CBP solution with a strategy designed to accommodate different learning styles

· Meet the current schedule of Provider Outreach milestones with the Provider Enrollment team

· Provide effective and efficient outreach and communication through numerous delivery methods

· Focus selective attention on specific provider education items

· Liaison with DOL medical staff on the OWCP programs

· Provide ongoing outreach activities after implementation

· Implement quality assessments and CBP community exchanges to evaluate the effectiveness of the Outreach program

1.2.1.5.2 CBP Portal

The CBP Portal will be the primary source for communication that, in addition to providing all billing, enrollment, status inquiry, and authorization services online, will also offer an online option for the educational components of the Provider Outreach program, and information dissemination in the form of:

· Training manuals (how-to instructions)

· Remittance Vouchers [RVs] banner messages

· Brochures

· Resource links

· Presentations

· Newsletters

· Provider enrollment forms

1.2.1.5.3 CBP Call Center

The Contractor will maintain a Call Center with trained staff prepared to assist providers who have questions about the CBP Program. Specific calls related to provider enrollment and other specialized issues will be escalated to the Provider Enrollment staff. Information provided to inactive providers will be limited to the period(s) of their valid enrollment. Call center scripting will be written to support the limitation of information given in these cases. Providers will also be advised on the procedures for re-enrollment as applicable.

1.2.1.5.4 Provider Training

The Contractor Training Manager will be responsible for the development of the CBP training program and will work closely with DOL personnel and the Provider Outreach Supervisor to ensure that all training objectives are met. Objectives of the CBP training program are:

· Ensure that training opportunities are available to all stakeholders, including DOL and contractor personnel as well as the Provider and Claimant communities, enabling a smooth transition during the Implementation and Operations phases of the project.

· Provide stakeholders with the skills they need to perform their jobs effectively and efficiently on Day 1 of operational cut-over.

· Ensure that all stakeholders are aware that training and reference material are available and work with the DOL to identify knowledge gaps to be addressed through training activities

· Provide a training environment that replicates the CBP production environment, providing hands-on and computer-based training (CBT) to CBP users

· Provide DOL-approved training and user documentation for all CBP components and functions

· Coordinate CBP training activities with those of the Provider Outreach and Communications programs to ensure that outreach and training activities combined will provide a comprehensive program that meets all DOL requirements

1.3 Provider Enrollment & Management Business Process Flow - DFEC The following diagrams capture the DFEC Provider Enrollment through Paper, Provider Enrollment through the CBP Portal, Express Enrollment, and Provider Maintenance Business Process flows.

1.3.1 Provider Enrollment Through Paper

This diagram provides the steps for processing a paper provider enrollment form that is received at the Central Mailroom. The input is the provider enrollment form, and the output is an RTP, denial of enrollment, or a new provider number.

1.3.2 Provider Enrollment Through the CBP Portal

This diagram provides the steps for processing a provider enrollment that is submitted online through the CBP Portal. The input is the provider enrollment data, and the output is a real-time error message, denial of enrollment, or a new provider number. Any Contract nurse or Voc Rehab Counselor enrollment application through the CBP Portal should get a denial message.

1.3.3 Express Enrollment - DFEC

This diagram provides the steps for processing a provider enrollment for a DFEC Contract Nurse, Vocational Rehabilitation Counselor, or other high priority enrollment per request by DOL. The input is the provider enrollment form from DOL, and the output is a new provider number, and a user ID and password to access the CBP Portal for bill entry.

1.3.4 Provider Maintenance

This diagram provides the steps for processing a request from a provider to change a provider name or identifier, an address, or EFT/ACH information. The input is the request from the provider, and the output is an RTP or confirmation of updated provider data.

2 Provider Enrollment and Management - DEEOIC

2.1 Provider Enrollment and Management Overview – DEEOIC

The CBP Provider Enrollment and Management solution supports maintenance of the provider file, provider enrollment processing, provider number assignment, and the provider outreach program to communicate program information, recommendations and updates to the provider and claimant communities. The Provider Enrollment and Management, and Provider Outreach functions will rely on the CBP Portal as the vehicle for providers to enroll, submit provider updates, and obtain program information.

2.2 Provider Enrollment and Management Business Process Description - DEEOIC The Provider Enrollment and Management component of the CBP program supports the enrollment of providers who complete the provider enrollment form successfully, and can offer validation of their stated status; the efficient maintenance and management of the provider file in medical bill process; and the outreach and communication with the provider community about program objectives and updates, DOL initiatives, and assistance with all elements of the CBP program.

2.2.1 Provider Enrollment Process

Current providers will have their provider numbers transferred to the new CBP system, and may continue to use their existing provider number for billing. New providers or providers whose previous numbers have been deactivated, with the exception of providers that have been excluded from the program, will be required to apply for a provider number by completing and submitting a provider enrollment form, either hardcopy or electronically through the CBP Portal.

2.2.1.1 Provider Enrollment Methods

Providers may submit hardcopy enrollment applications that can be downloaded from the CBP Portal, or mailed directly to the provider by a Call Center representative, upon request. Providers may also submit an enrollment application online by accessing the public CBP Portal and stepping through each required field.

2.2.1.1.1 Hardcopy Enrollment

Hardcopy enrollment forms and attachments are received at the Central Mailroom . These documents will be scanned and forwarded directly to the Provider Enrollment Unit through the workflow (details of which will be provided in the training materials) for screening of the entire enrollment form to ensure all pertinent information is present (signatures, addresses, names, licenses/certifications, and other information). If required data is missing, the Contractor will prepare the RTP form to be submitted back to the provider indicating which information is missing from the enrollment submission. If the enrollment submission contains all the necessary information, the representative performs provider credential verification. If the representative is able to validate the provider’s license/credentials, the enrollment completes processing through the medical bill process engine, and a provider number is assigned. The provider number, CBP Portal login credentials, and welcome package will be sent to the provider via email or hardcopy.

2.2.1.1.2 Online Enrollment

Online enrollment applications will be entered into the CBP Portal by the provider. The submitted data will be processed through the medical bill process engine, and if up-front data validity edits identify missing or invalid data, the provider receives a real-time message via the Portal indicating that information is missing or invalid. If the enrollment data passes the up-front edits, the data will be transferred by the workflow to a Provider Enrollment representative to perform provider credential verification. If the provider passes the credential verification, the enrollment completes processing through the medical bill process engine, and a provider number will be assigned. The provider number, CBP Portal login credentials, and welcome package are sent to the provider via email or hardcopy.

2.2.1.1.3 Faxed Enrollment

DEEOIC high priority (i.e., express) enrollments may arrive via fax, email, or mail for certain provider types, and require expedited processing as requested by DOL. In these cases, the provider information on the enrollment is reviewed and validated by the DOL staff, and the enrollments are faxed to a dedicated fax machine at the Central Mailroom. These express enrollments are clearly identified by a cover sheet that has been signed by a DOL representative. Since the enrollment forms are already verified by DOL, the Mailroom staff performs only a cursory review of the forms prior to scanning and data entry. If any of the data validity checks identify missing or invalid data, the Mailroom staff or Provider Enrollment staff will contact DOL immediately to try to resolve the issue, in the interest of supporting an expedited enrollment. After an enrollment is successfully processed, the Provider Enrollment staff will fax provider numbers and login credentials back to the DOL representatives.

Enrollments may arrive via fax, email, or mail for other provider types, and require expedited processing as requested by DOL.

2.2.1.2 Provider Enrollment Qualifications

The CBP Provider Enrollment Team will be responsible for verifying and validating certain provider credentials before a provider is certified to participate in the CBP program. The Provider Enrollment representatives will work closely with providers who do not initially submit the proper documentation in order to facilitate an expeditious enrollment. If a provider fails to provide the required credentials and cannot be reached within a reasonable amount of time, the enrollment will be returned as RTP.

2.2.1.2.1 Inpatient/Acute Care Hospitals

The Contractor will review the enrollment application for providers enrolling as inpatient/acute care hospitals (provider type 01) to see if a Medicare letter has been included. If a Medicare letter is not included, the Contractor will validate the provider’s Medicare certification by checking against State and CMS data (the American Hospital Directory or the National Plan and Provider Enumeration System [NPPES] websites), the CMS excluded provider file, and provider-supplied information.

2.2.1.2.2 DME Providers

The Contractor will validate that providers enrolling as Durable Medical Equipment (DME) providers (provider type 75) have posted the required bond by checking the DMEPOS file supplied by Medicare. If the provider has not registered with Medicare, the Contractor will conduct provider outreach notification.

The Contractor will receive the DMEPOS file from CMS of all DME providers registered to provide and disburse DME equipment, supplies and devices. Any providers enrolling as type 75 will be verified against the DMEPOS file. If there are DME providers currently enrolled and not found on the CMS DME Provider file, the Contractor will conduct provider outreach to confirm the provider’s status.

2.2.1.2.3 State Licensure

Providers who enroll in the CBP will be required to provide their license information on the enrollment form, and to submit proof of state licensure according to their provider type. The Provider Enrollment team will review the submitted documents to establish if a license copy is present for all provider types on the application. If a license is attached, the representative will verify the information using State Licensure websites. If a license copy is not attached, or the license number is handwritten, the representative will return the enrollment application to the provider with an explanation of what is required.

For group providers, individual license copies for each provider in the practice, up to nine (9) licenses, must be submitted and individually verified. For groups of over 9 providers, the group license is validated, but the group practice is responsible for verifying the licensure of the individual providers.

In all cases, if a license cannot be sufficiently verified after 2 attempts within 2 days by the Provider Enrollment team, the enrollment package will not be processed, and will be returned to the provider with an explicit explanation of what is needed in order to fulfill the enrollment application requirements.

2.2.1.2.4 Other Provider Licensure Exceptions/Considerations

2.2.1.2.4.1 DME Provider

The Contractor will receive the DMEPOS file from CMS on a frequency to be determined, containing all DME providers that are registered and bonded by CMS as a DME Provider. The Contractor will apply those providers to the CBP Provider file as (Provider Type 75). The DMEPOS File will be provided to the contractor directly from CMS.

Additionally, if any of these providers are excluded for any reason, CMS would disseminate that information to HHS, who would in turn send OWCP the excluded file. OWCP will provide the Contractor with the exclusions, and the Contractor will follow their processes for updating their provider file accordingly.

2.2.1.2.4.2 MRI Facilities

Certifications or proof of inspection certificates are acceptable documents for freestanding MRI facilities without a license.

2.2.1.2.4.3 Ambulance/Fire Department

Certifications or a paramedic’s license(s) are acceptable documents for verifying an Ambulance/Fire Department without a license.

2.2.1.2.4.4 Providers in states that do not require a license

A license to treat patients and provide medical care is required from any provider, regardless of whether it is restricted to one state, or if the provider possesses a full unrestricted license allowing him to provide medical services in other states based on his/her specialty. If the CBP Provider enrollment unit receives a provider enrollment application that indicates that their state does not require a license or certification, the provider must provide an official letter from the state stating that the specific state does not require a certification or license in the Medical Specialty for which the provider is trying to enroll.

2.2.1.2.4.5 License Renewal and Expiration

The provider file in medical bill process will store license expiration dates, and will contain a mechanism for flagging providers with licenses that will expire in 60 days and 30 days. The Provider Enrollment Team will be responsible for sending letters notifying providers whose licenses are scheduled to expire in 60 days, and 30 days. The letter sent to providers whose licenses are scheduled to expire in 30 days will also provide a notification that payments will cease 31 days after license expiration. Information about license expiration will be available to all providers through the CBP Portal. However, the Provider Enrollment team will make every effort to conduct outreach with providers in order to obtain proper license renewal documentation.

The Contractor will accept and process provider license renewals within 60 days from initial notification of license expiration. If a provider’s license expiration is within 30 days of the processing date of a submitted claim, and the bill is in suspense, the Contractor will process the bill and notify the provider via adjudication of the bill (via the RV) that the provider license will be expiring within 30 days.

If the license expiration date of a submitted license copy is within 30 days of the enrollment processing date, the enrollment documents will be returned as RTP, and the provider will be advised to submit an updated license copy. If the Provider Enrollment representative can locate a license for the following year on the State Licensure website, it is acceptable to use the current license (as it is possible the provider may not have received the new license yet). Otherwise, the provider must submit another license with a new expiration date before the current license expires. The Provider Enrollment Team will verify the license with the state of licensure when a new expiration date is provided.

The medical bill process will automatically deactivate a provider 31 days after the expiration date on file if updated license information is not submitted, and will modify the provider status to reflect license expiration.

2.2.1.2.4.6 HHS Excluded Provider File

The Contractor will check each provider’s status against the current HHS Excluded Provider File prior to completing enrollment processing. If a provider is on the Excluded list, the provider will not be enrolled in any OWCP programs, and will be notified as such. Additionally, the Contractor will notify all claimants under that provider’s care. The Contractor maintains updates to the HHS Excluded Provider File as supplied by DOL.

If a provider becomes re-eligible after being excluded, the provider must submit a new enrollment form for complete processing through the cycle, along with an official reinstatement notification.

2.2.1.2.4.7 Multiple Licenses

If multiple licenses are submitted with different expiration dates, the Contractor will use the license with the greater expiration date provided. In addition to verifying the expiration date, the Contractor will also verify the issuing state(s) of the licenses.

2.2.1.2.5 District Medical Consultant (DMC) Providers

The Contractor will not enroll District Medical Consultants (DMC) providers (provider type 33) under the DEEOIC program unless approved by the National Office.

2.2.1.3 EFT and EDI Enrollment

As part of the CBP provider enrollment process, the Contractor will provide information about enrolling in EFT (mandatory) and EDI as a way of expediting and managing their bill processing and payments more efficiently.

2.2.1.3.1 EFT Enrollment

The Contractor’s provider enrollment process will identify providers who can receive payment via Electronic Funds Transfer (EFT). For new providers, EFT enrollment is required by DOL. New providers who submit an enrollment to the CBP program must complete an EFT form.

The Provider Enrollment team will be responsible for verifying the financial information provided on the EFT enrollment form before facilitating the completion of the EFT enrollment. Providers may sign up for more than one EFT account, which will have its own date span and status indicator in medical bill process. The Contractor also will update medical bill process with EFT notification of change information received by the U.S. Treasury, via DOL, and will retain both the old and new EFT information on file. The Contractor will promote EFT enrollment through its Provider Outreach campaign.

2.2.1.3.2 EDI Enrollment

The Contractor will strongly encourage CBP providers to submit bills electronically through participation with Electronic Data Interchange (EDI) services as defined by DOL. The Contractor’s EDI campaign initiated by the Provider Outreach Program and offered through the provider enrollment process will supply the necessary guidance to providers on how to enroll into the service, or will provide their EDI information if they already have e-Bill Submit capability.

2.2.1.4 Provider Activation and Deactivation

New providers will be activated in the CBP program within 5 days after submission of enrollment forms that have been successfully processed. The Contractor will maintain provider records that show the following data elements, at a minimum:

· All provider identifying information

· The program(s) in which the providers participate

· Unique provider identifiers showing status (enrollment/active/exclusion/on review, etc.)

· Other provider classifications

· Provider type

· Locations

· Group affiliations The Contractor will automatically deactivate providers who appear on the HHS Excluded File, which will reflect current updates in medical bill process, and will be matched against the current provider file; providers who have gone two (2) years without activity since their last bill submission; providers whose licenses have expired, and manually, on a case-by-case basis, upon DOL direction.

Bills received from an inactive provider will be returned as RTP from the Mailroom if the date of service is after the effective deactivation date. Bills or adjustments from an inactive provider will be processed if the date of service is before the effective deactivation date. Bills or adjustments from excluded providers will always be returned as RTP regardless of the date of service.

Any bills processed against providers who were deactivated due to exclusion while the bill was already in process, will post the corresponding edit indicating the provider is deactivated due to exclusion, and will be denied, regardless of the date of service of the bill. For any provider that has been deactivated due to any reason other than exclusion, an effective date of deactivation should be applied to continue bill processing and adjustment processing for dates of service that fall prior to the effective deactivation date.

2.2.1.4.1 Provider File Management

Maintaining up-to-date provider files is critical for the accurate processing of bills and authorizations, as well as for the integrity of the provider file. The Contractor’s provider management processes will accommodate the prompt update of provider files, and the efficient maintenance of all paper files.

The Contractor will track and log all maintenance activities using the date/time stamp of when the update or inquiry occurred, and who performed the update or inquiry. Queries for these updates will be accessible through the search functionality built into the CBP Portal, and can be sorted according to specialty, address, name, and ZIP code.

2.2.1.4.2 Provider File Maintenance

The Contractor’s medical bill process will support provider file records that contain all available provider information including:

· Provider numbers, NPI, Medicare, etc.

· Owners

· Affiliations

· Locations

· Specialties

· Taxonomy

· Category of Service (COS) mapped to Provider Type

· Addresses - The medical bill process will support provider record indicators for multiple provider addresses for each individual provider record, to include the primary office location, pay-to address, and Remittance Voucher (RV) address

· Contacts

· Licenses – The medical bill process will track an unlimited number of provider licenses for any number of states for any given provider. Each license entry on the provider record will have an effective “from” and “to” date range, allowing for accurate tracking and application of provider licensure data.

· IRS Levy status – DOL will provide the Contractor with the IRS levy and “Release of Levy” files as needed, and the Contractor will update the provider file in medical bill process accordingly so payments can be redirected accordingly.