In many states, the law requires carriers to pay for covered services provided to the member during the credentialing process at the in-network benefit level and under the terms of the contract. To apply, the credentialing application must ultimately be approved by the carrier.

Credentialing Requirements

All health plans are legally required to use a database that is created and maintained by OneHealthPort/Provider Source for credentialing purposes. This includes non-delegated credentialing, where the medical staff services department of a clinic, a hospital, or a health system collects credentialing data directly from physicians or other practitioners.

How Long Does Credentialing Take?

Once it is collected and submitted as part of a credentialing application for each specific provider. It can sometimes take several months for the presiding health plan to verify the credentials and approve or deny them for reimbursement. This type of delay creates the need for a retroactive reimbursement system.

What Is Retroactive Reimbursement?

To meet the legal requirements for carriers to pay for covered services provided to a member during the credentialing process, the credentialing application needs to be approved by the carrier. Ideally, Reimbursement would begin on the date the completed credentialing application was received by the carrier or perhaps the “Effective Date” that the contract was started between the carrier and the provider.

Should the credentialing application be delayed or denied or the date of service between the carrier and the carrier is after the application is approved, it would technically be considered to be “Out of Network” and reimbursement payment would be paid as such.

What Is OneHealthPort?

Often referred to in the industry as “OHP,” OneHealthPort was specifically developed for the healthcare industry. It uses an innovative single sign-on access to the system, which enables healthcare professionals to have a single, secure and easy-to-use method of access to important provider portals. This includes portals for major local health plans, clinics, specialty services, and major hospitals. It continues to grow in popularity, which further helps streamline the credentialing process.

It’s also worth noting that OHP is governed by leading local healthcare organizations. This august body includes private physicians, hospitals, health plan representatives, medical specialists, administrators in the healthcare industry, and associations. It is focused on connecting healthcare organizations to make patient care safer, as well as helping communities to be healthier by expediting the delivery of health services, data, and critical information in a way that is more efficient. This sometimes includes partnering with national organizations that have similar goals to help OHP to serve broader populations.

The system went online in 2002 and has continued to grow. Today it is affiliated with over 75,000 clinics, hospitals, and provider institutions. Every year OHP processes over 50 Million transactions, with over 100,000 active subscribers.

Can Medicare Be Billed Retroactively After Credentialing Approval?

Retroactively billing Medicare can be complicated early on, as technically the provider or billing organization needs to have a Medicare number. This can be complicated by how long the provider enrollment process takes Medicare to process the information.

This means that all retroactive periods essentially start only after the application has been submitted, yet the application submitted will still need to be approved. In a case where the application is denied due to something like incomplete data, an improperly used code, or the application is rejected due to the provider not technically meeting Medicare’s established standards, you could likely lose the retroactive billing date. This would require you as the provider to start the laborious application process all over again.

This is just one of the many reasons why it is so important to stay on top of the Medicare enrollment process to confidently ensure that your application is processed promptly and without any other issues or delays. If you need to mail documents or any other materials to Medicare, make sure to send certified and keep a copy of the tracking certificate.

Do Retroactive Reimbursement Claims Require A Special Modifier?

When it comes to retroactive reimbursement claims, you don’t need a special modifier. As the provider, you simply submit the claim the same way you would any other and use the CPT code for the visit the same way you would if you were already an active participant.

Timelines For Retroactive Reimbursement

When it comes to Medicare claims, the timely filing rules are effectively waived during the initial enrollment period. The Medicare system understands that the application is still being processed. Though if the claim is denied or delayed it could require you to submit additional documentation. So, it’s important to always keep copies of all approval letters and applications.

Medicare also notes that the effective date is the later of the following two dates. This also means that the filing date of an enrollment application is subsequently approved, or it is the date the provider first started offering services at a new clinical location.

Medicare also states that the provider may only bill services retrospectively when the supplier has met all program requirements and that the services were provided at the enrolled practice location. It must be no more than 30 days before the effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or up to 90 days before their effective date. Though the 90-day period technically requires the event to be a presidentially declared disaster that precluded enrollment in advance of providing services to Medicare beneficiaries. The retroactive claim must also include all critical information including all pertinent state licensure requirements, and the enrolled practice location.

Partnering With Medical Billing Professionals

One of the great things about partnering with a third-party medical billing service like Operant Billing Solutions is that our experienced technicians are well-versed in the fine details associated with retroactive reimbursement requirements and how they pertain to the credentialing process. We can demystify the process, and make sure that all the necessary information is coded and presented to Medicare and other payer institutions in the format they prefer. This will go a long way toward preventing unnecessary delays, while also reducing the risk of a claim being denied.