As a result of the work done under a Samuel Fels Foundation grant, NNCC has found that despite favorable legal authority, many health insurance companies are not contracting with NPs as PCPs individually or as specialists. Each company follows its own business decisions and therefore carriers in the same state can have different policies. We are trying to assess which companies are contracting with NPs and if not, what and where are the stumbling blocks. This Health Insurance Company Contracting Tool Kit is intended to walk you through the contracting process in a user-friendly way. Our goal is to support your being credentialed and reimbursed by health insurers for your services, making NPs a financially sustainable part of the safety net. We need you to help us build a record of which insurance companies, in what markets, continue to resist contracting with NPs in Nurse-managed Health Clinics. At that point, NNCC will move forward with contacting that insurance company to educate and try, in a focused way, to change their NP contracting policy. Please pursue PCP status with your local insurance companies NOW.
Review the explanation of CAQH if you are not familiar with their involvement in the credentialing process.
Refer to the listing of insurance carriers to locate the companies in your state. Under each company's name is the contact information needed to request an application for network participation with the company.
Once your application request has been made to the insurance company the following general process will occur (although there may be some differences in flow with some companies):
Your initial request for an application is just that - a "request for"-not the actual application. Your request may be made with the insurance company itself or through CAQH. When this request reaches the credentialing department of the company, the credentialing department confirms the company's "need" for that provider type in that particular area in a "needs" database. If the "need" is there, you will then be contacted with an application and the process will continue. If there is no "need", the company will regretfully deny your request.
This "needs" database is populated by the provider business unit (or provider contracting). If they do not include NP's in the database as needed or accepted in the area, then credentialing cannot move forward with the application process.
Please contact NNCC with any problems or concerns along the way. Once you are notified of your acceptance or rejection from the network, we would like to know. If necessary, we want to assist in educating these companies on the law and hopefully changing their business decisions.
Sarah Hexem, JD
Some MCOs have contracted with the retail clinics as a facility. The retail clinic receives a flat fee per encounter. The amount of the flat fee depends on the complexity of the case, if the patient is an existing patient or new patient, and if there was a vaccine administered or not. When they contract a facility, there is no credentialing process and no site visits required. NOTE- they are not contracting with the NP's individually as PCP's and therefore no payment is made to the NP directly. The NP is paid by the facility.
1. Concerns - because NP not contracted as PCP…