Universal Credentialing DataSource
Overview for Participating Organizations
An Introduction to CAQH
The Council for Affordable Quality Healthcare (CAQH) is a not-for-profit
alliance of health plans and networks that promotes collaborative
initiatives to:
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Make healthcare more affordable
Share knowledge to improve quality of care
Make administration easier for physicians and their patients
Member Organizations
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Areas of Focus
CAQH is working in two major areas with focus on designing and
implementing achievable, concrete initiatives:
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Administrative Simplification
Making administration easier for
physicians and consumers
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Quality of Care and Patient Safety
Working with physicians and
professional organizations to
improve overall health care quality
through national initiatives
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Universal Credentialing DataSource
Formulary DataSource
Industry Standard Terminology
Save Antibiotic StrengthSM
HeartBBEAT for LifeSM
Administrative Simplification:
Universal Credentialing DataSource
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What Is Credentialing Today and Why Is It Done
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Systematic process employed by health plans, hospitals and other
healthcare organizations to determine whether providers meet each
organization’s respective quality standards for participation.
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Performed by virtually all organizations for network quality, risk
management and accreditation reasons.
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Data collected via credentialing processes may be used within other
business areas such as contracting, provider directories, member
services and claims processing.
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Return on investment is difficult to measure.
What Steps Are Involved
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Credentialing
Data Collection
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Credentials
Verification (PSV)
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Credentialing
Review and
Decision
1. Health plans, hospitals and other organizations typically use paper
applications to collect self-reported data from providers (education,
training, experience, etc.).
2. Each organization then verifies certain provider-reported data against
primary sources (Primary Source Verification or PSV) either internally or
via a Credentials Verification Organization (CVO).
3. The organization presents the verified information to a review committee
who makes an independent decision about whether the provider in
question meets that organization’s standards for participation.
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Data Collection Is the Most Inefficient Step
0%
40%
25%
35%
Obtaining a complete application
Primary Source
Verification
File preparation, committee
review, appeals, etc.
20%
• Manual process, usually
involving combination of mail,
fax, phone, and sometimes
even office visits
• Requires long lead time, and is
primary reason why process
begins 4-6 months before
actual decision is made
• Once application is complete,
remaining steps proceed
quickly
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40%
60%
• Automated
process in most
larger plans
• Sometimes
involves
expensive
licensing fees
and strict
sharing
restrictions
• Third-parties
often involved
*Based on discussions with health plan representatives
80%
100%
• Moving toward automation;
business rules enable plans
to identify providers who
require further research
• Major component of file
preparation is ensuring
time-sensitive information
meets freshness standards
when presented to
committee
Problems with Traditional Data Credentialing Processes
The first step of the credentialing process has the following problems:
• Redundancy: Providers are asked to complete multiple forms
essentially requesting the same information.
• Follow-up: Omitted and illegible responses requires significant
resources and result in delays to timely processing.
• Misalignment: Different credentialing cycles exacerbate the problem
by requiring providers to complete the process at different points in time
for different health plans and other organizations that perform
credentialing.
• Off-cycle updates: Diligent follow-up is required to maintain accurate
data between credentialing events so that provider directories, referral,
claims and other provider and member services are effective.
• Turnaround: Providers are frustrated with time between application
submission and when a decision is finally communicated back despite
significantly improved processing by health plans
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The Solution: Universal Credentialing DataSource
One physician, One application, One source
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Replace multiple plan-specific paper processes with a single, uniform
data collection system
Key features include:
– Completely free for providers to use
– Providers can complete application online via interview-style questions or
fax paper copy
– Supporting documents are collected, imaged and attached to electronic
record
– Participating organizations can access data in electronic format at any time
if authorized by provider
– Data maintained in a “Perpetual State of Readiness” to avoid problems with
differing recredentialing cycles – refreshed every 90 days
– Updates can be made at any time and are immediately available to
authorized organizations
– 128-bit Secure Socket Layer Encryption (SSL)
– Toll-free help desk to assist providers
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Basic Overview
Provider
Advisory Panel
Mid-level
Providers
Allied Health
Providers
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User Group
Health Plans
CAQH
Universal
Credentialing
DataSource
Data Access System (DAS)
Podiatrists
Online Application System (OAS)
Chiropractors
Via
Internet
or Fax
Practice Administrator Module
Physicians
CAQH
- - - - - To be implemented in 2004
Hospitals
Other
Healthcare
Organization
s
Benefits for Participating Organizations
Participation in the Universal Credentialing DataSource initiative offers the
following benefits to health plans, hospitals and other healthcare organizations:
• Flexibility: Participating organizations are free to independently determine
best options for primary source verification, including internal and third-party
avenues.
• Affordability: Not-for-profit status ensures that fees are kept low, and any
revenue beyond expenses are redirected toward further system
improvements.
• Efficiency: Typically redundant data collection efforts are replaced with
single, industry-wide system that allows participating organizations to focus
on using data rather than chasing applications.
• Automation: Availability of electronic data enables participating
organizations to move away from manual, paper-based processes.
• Provider Relations: Participation in initiative demonstrates leadership in
industry and willingness to alleviate key factors in provider dissatisfaction.
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Areas of Impact for Participating Organizations
Tier 3: Other Inefficiencies
Tier 2: Non-Credentialing Costs
Tier 1: Direct and Indirect Costs
• Pre-population and preparation of
application
• Mailing/handling of application (sendout and receipt)
• Follow-up contacts to providers,
“chasing” of application
• Application completeness review
• Data entry and/or scanning of
applications and supporting documents
• Archiving and offsite paper storage
• IT support for application database
maintenance
• Provider relations field activity
associated with follow-up
• Management
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• Provider directory
maintenance
• Other member
service functions
• Recruiting and
network
development
paperwork
• Provider data
maintenance and
other plan-wide IT
operations
• Application and
supporting
document storage
and retrieval
• Data errors and
inconsistencies
across
departments
• Inefficient claims
processing due to
erroneous billing
information
• Lack of electronic
contact
information for
provider relations
activities
• Hassle factor for
providers
Early Results from Current Participants
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Reduced Mailings: After 20 months of
aggressively promoting the CAQH
credentialing initiative, 72% of a plan’s
providers in Colorado have successfully
completed their applications – no more
outreach required
Result: 36% fewer providers to contact
via mail each month during remaining
16 months of 3-year recredentialing
cycle
Paperless: While an automated solution
is being developed, a plan’s data entry
personnel currently toggle between
CAQH-supplied electronic images and
their respective data entry screens
Turnaround: One plan has found that
applications submitted via the CAQH
system usually require little follow-up
with provider offices
Result: Quicker plan credentialing
decisions on CAQH applications
Automation: One plan downloads raw
data directly from the CAQH system into
its provider data system, which in turn
feeds other systems.
Result: Reductions in data entry
resources, and improvement in data
quality
Result: Reductions in printer costs,
paper procurement, filing needs and
offsite archiving because applications
can be viewed and stored electronically
Media Coverage Highlights to Date
Health plan group offers one-time credentialing
Health plans want physicians to say goodbye to paperwork and hello
to a central database.
Universal Online Credentialing
System Promises Efficiency,
Simplicity
Healthplan Magazine
Simpler All Around
Lightening doctors’ administrative load can improve relationships
Online Credentialing Solution Wins Support as
National Rollout Continues
Credentialing made easy
Health plans have created a one-stop service. We took a look to see how
well it works.
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How It Works
1. Participating health plans and other healthcare organizations submit a roster of
their respective providers to CAQH. Alternatively, health plans can create their
roster online via the participating organization side of the system – called the
Data Access System (DAS).
Online tool to help
participating
organizations add
providers to their
roster
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How It Works
2. CAQH mails Registration Kits to all unique providers appearing on at least one
submitted roster. The Registration Kit contains a unique CAQH Provider ID, as
well as instructions on how to access the provider side of the system – called
the Online Application System (OAS).
Welcome screen
for Online
Application System
(OAS) where new
users can register
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How It Works
3. Once in the system, the provider creates a username and confidential password.
With this username and confidential password, the provider can begin to
complete the application online. If the provider prefers, a paper application can
be requested from the toll-free help desk.
Interview-style
questions help
providers navigate
application one
section at a time
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How It Works
4. Before the completed application is available to any participating organization,
the provider must authorize release of his or her data. All of the organizations
who have included the provider on their respective rosters are listed here for the
provider to review and authorize.
Authorization screen
ensures providers have
complete control over
which organizations
have access to their
information
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How It Works
5. The provider must then generate a fax cover sheet and fax any required
supporting documents to a toll-free fax number. These documents are imaged
and attached electronically to the provider’s file.
The last step for
providers is to fax all
necessary supporting
documentation
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How It Works
6. Once the application is complete, authorized participating organizations are sent
data in their preferred format: (A) ASCII; (B) XML; or, (C) static PDF images of
applications. Subsequent updates to data are also available in the same
formats.
A
B
C
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Complete applications
can be retrieved by
participating
organziations in the
format of their choice
Who Is Involved So Far?
The list of participating organizations continues to grow, and includes nonmember organizations (as of 2/12/04):
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Aetna
Anthem Blue Cross and Blue Shield
AultCare
Blue Cross Blue Shield of Georgia*
Blue Cross Blue Shield of
Kansas City
Blue Cross Blue Shield of Michigan
Blue Cross Blue Shield of Missouri*
Blue Cross Blue Shield of North Carolina
Blue Cross of California*
CareFirst Blue Cross Blue Shield
CIGNA Healthcare
Culpeper PHO
Community Care Physicians
Empire Blue Cross Blue Shield
Excellus Health Plan
The First Health Network
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Great-West Healthcare / One Health Plan
Health Net, Inc.
HealthLink*
HealthPlan of Michigan
Horizon Blue Cross Blue Shield of New
Jersey
Independent Health
Kaiser Foundation Health Plan of the
Mid-Atlantic States
MAMSI Health Plans
MultiPlan, Inc.
Oxford Health Plans
Preferred Care
Rocky Mountain Health Plans
Sentara Healthcare
UNICARE*
Virginia Premier
* Part of WellPoint Health Networks
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Progress to Date
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Over 42,000 providers have already successfully completed the CAQH
application via the paper or online process and the numbers are
increasing daily
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Launched in 43 states and District of Columbia (as of 2/12/04;
remaining states to launch shortly)
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Over 69,000 providers have already registered with system in all
launched markets
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Providers who have used the Universal Credentialing DataSource thus
far have relationships with an average of 4 participating organizations –
over 160,000 legacy credentialing applications have been eliminated
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Once complete, providers will no longer need to submit additional
credentialing paperwork as new organizations join initiative
Costs
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The CAQH credentialing solution is completely free for providers to
use.
Participation is offered to all organizations – membership in CAQH is
not required.
Participating organizations are charged a standard fee per provider per
year for unlimited access to data and any updates received, plus a
small annual administrative fee for the organization overall – just
enough to cover the operating costs
Organizations will only be charged for providers whose applications are
complete and are authorized for release
Automation and timely provider data will likely result in
organizational savings that offset the costs to participate
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How to Get Started
1. Contact CAQH for more information:
Atul Pathiyal
Project Director, Credentialing
apathiyal@caqh.org
202-778-3285
2. Schedule system demonstration
3. Review and execute contract
4. Prepare roster of providers and submit to CAQH
5. Begin downloading provider information from Universal Credentialing
DataSource
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www.CAQH.org
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