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  • Credentialing > Provider Data Validation During the Credentialing Process

    New York State and Federal regulations require EmblemHealth to maintain the accuracy of its provider file data, to ensure its Provider Directories meet basic information requirements and accuracy.

    Through the initial credentialing and periodic recredentialing processes, EmblemHealth validates the accuracy of a provider’s service location data by reviewing against the provider’s data in CAQH ProView™ and performing telephone outreach.

    CAQH ProView, formerly the Universal Credentialing Datasource®, was founded in 2002 to address the biggest challenge with provider credentialing. Data collection had been the most inefficient step of the credentialing process, placing unnecessary burden on providers. Previously, providers completed separate credentialing forms for each payer.

    EmblemHealth’s data validation process leverages the data in CAQH ProView as the “source of truth” for service location data. Only service locations listed on CAQH Proview are eligible for validation, enrollment at initial credentialing or continued participation at recredentialing. Service locations not listed in CAQH ProView will be subject to validation by phone call and possible termination if unreachable or non-responsive.

    To avoid a failed validation, denial of enrollment or possible break in service, please ensure your CAQH profile is up to date with all service addresses and telephone numbers where you take appointments.

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    Glossary terms found on this page:

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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