Expert Radiology Credentialing Service for Imaging Practices

Your new radiologist is ready to read, but the payer is still showing them with their former group. Or your reading group is getting paid while the claims from the new MRI site are getting kicked back. Our Radiology Credentialing Service helps Imaging teams across the U.S. with application enrollment and follow ups, and provides the information needed for billing to release claims.

We help radiology practices, freestanding Imaging centers, Hospital Radiology Departments and Teleradiology Groups. A project can be for a new hire, new site, backlog applications or ongoing renewals. We come to agreement on the providers, payers and locations in scope and your team knows what work we’ll do, and what decisions they’ll need to make.

A Radiology credentialing service aids radiologists, groups and Imaging facilities to prepare qualification records, complete payer enrollment applications, coordinate applicable licenses and privileges and verify participation before claims are released. The service could cover recredentialing, Medicare revalidation and any practice or group change.

What our radiology credentialing service covers

Credentialing ensures that the practitioner’s qualifications, licensing, professional history, and clinical privileges are in order. The organization’s network status and prior billing information are ensured through payer enrollment and contracting. The next step involves the entry by the payer of the authorized provider, group, and location in the claims system. This is often coordinated by the Medical Billing Services.

Payer Enrollment, CAQH, NPI, and Group Linkage

We can enroll providers in Original Medicare through PECOS and assist with applications to state Medicaid, managed care, and commercial payer programs. An insurer can administer a commercial PPO, an exchange plan, and a Medicare Advantage plan, and each product may have different participation agreements. We confirm each product in scope with the group’s tax ID and the sites that will submit claims.

We assist with the CAQH Provider Data Portal and ensure participating organizations have access as needed. We also facilitate attestation with the clinician. CAQH members can use this information in their credentialing. Each payer’s processes, contracts, and roster requirements are separate. With CAQH, begin with the most accurate provider information and assess the sites and services that need to be added for each plan.

We reconcile the individual Type 1 National Provider Identifier (NPI) of the radiologist, the Type 2 NPI of the organization, if any, the billing TIN, Specialty taxonomy codes, and approved locations. CMS, via PECOS, uses the electronic version of the CMS-855I for individual physician enrollment and reassignment. Group practices and other suppliers use the paper version, CMS-855B, for their own enrollment. A radiologist already enrolled with CMS may need reassignment to a different group. Similar to CMS, some commercial plans use a Roster Add or an Affiliation Request to effect a similar operational change.

State Licensing, DEA Registration, and Hospital Privileges

When in scope, we are able to complete state medical license applications, gather supporting documents, and manage requests and renewals. For remote readers, confirm the state rules that apply to the location where the patient receives care, and review the reading location for additional requirements. The state licensing board makes the final determination for licensure, and the physician provides the required signatures and attestations.

We are also able to track the DEA and state controlled-substance credentials where applicable. Confirm the role and state and facility requirements where applicable. An interventional radiologist’s responsibilities with respect to controlled substances may differ from a physician whose role is limited to remote diagnostic interpretation.

Hospital privileging provides an opportunity for forms, references, case log reviews, and follow-up with the Medical Staff Office. Required documentation for approval of diagnostic reads and image-guided procedures varies between hospitals. The National Committee for Quality Assurance (NCQA) publishes credentialing standards that guide verification of the practitioner’s qualifications. The Joint Commission provides guidance on hospital credentialing and privileging. The organization reviewing the file applies its own requirements and makes the approval decision.

Recredentialing, Medicare Revalidation, and Rosters

Recredentialing is a periodic review of a practitioner’s or supplier’s qualifications to practice by a payer or facility. Medicare revalidation is the affirmation by CMS of a provider or supplier’s record to verify that it is current. Keep distinct tasks for CAQH reattestation, license and malpractice renewals, facility reappointment, Medicare revalidation, and applicable imaging accreditation or certification. Assign an owner and a source for each task’s due date.

Maintaining your roster requires changes due to departures, ownership and billing entity changes, new sites, and adjustments to a clinician’s scope of practice. When a reader leaves, there may still be work in the billing queue after that individual is removed from the schedule. It’s important to track the last covered service date, the payer’s roster change, and the outstanding claims to assist the billing team with reconciling all of the data.

Records your practice receives

You should expect a radiology credentialing service to leave your staff with records they can use. You should define a deliverable for each file as a submission receipt, an open-items report, or a handoff note and approval to bill. A payer application may have multiple outstanding requests. The report should identify which request is pending and who can resolve it.

To begin clearing a backlog, find out what applications are pending. Request the payer’s reference number, the date and description of the most recent request made, the contact person, and the due date for the response. An expired signature on an active application should be handled in a different manner than an application that was closed and is in need of refiling. The right follow up can also assist with preserving billing history

Imaging Billing Determines Enrollment

Imaging billing ultimately determines enrollment. The same diagnostic study can have a professional and technical component. Where code, setting, and payer permit component billing, modifier 26 identifies the professional component and the technical component is claimed separately. A global claim joins both components in a single claim where the billing entity is eligible to report both. The credentialing file should reflect actual billing arrangement.

Reading Groups and Hospital Departments

If a hospital performs a study and an independent group bills the interpretation, the hospital follows its facility billing arrangement and the reading group verifies the radiologist’s relationship to its own billing entity. For a new reader, confirm the hospital’s granted privileges, the group’s payer arrangement and the applicable individual reassignment.

A hospital can clear a radiologist to read CT while the payer is still processing the physician’s addition to a contracted group. In this case, the practice manager needs to be clear to bill and collect for the service. The hospital’s medical staff office grants the privilege to read CT. The payer grants participation.

Freestanding Imaging Centers and IDTFs

Some imaging suppliers enroll as an Independent Diagnostic Testing Facility (IDTF). The right enrollment route depends on the entity’s operation and billing practices. Verify the supplier type with the MAC. If IDTF rules apply, provide the location and equipment information, and the name of the supervising personnel and technologist, and plan for a potential site survey.

Review the technical-component accreditation for the appropriate modality (e.g. CT, MRI, nuclear medicine, etc.) for the location being supplied. The organizations recognized by CMS for advanced diagnostic imaging accreditation include the ACR and The Joint Commission. Mammography has its own facility certification and personnel qualifications under the Mammography Quality Standards Act (MQSA). If your center is adding breast imaging, review the facility certificate and the qualifications of the interpreting physician during the launch.

Example. A freestanding center opens a second MRI suite, and its independent reading group submits the interpretation claim and gets paid. However, the center’s technical claim for the MRI service is denied. First, examine the entity and address on the technical claim and compare them to the suppliers’ approved enrollment, accreditation, and the payer’s site record. If only one site is recorded, document the missing site, route the correction to the enrollment team, and decide which service dates the payer will accept. Then, billing can edit the affected claims.

Teleradiology groups and Interventional radiologists

Remote Radiology Medical Credentialing Services should retain a clear record indicating which readers are approved at which hospitals, payers and locations. If the credentialing team can confirm the physician has a recognized state license, approved hospital privileges and scope of service, and reporting responsibilities, the team may consider using credentialing by proxy, provided the team verifies a written agreement exists and oversight of the physician meets the applicable requirements. Payer enrollment and group affiliation follow a separate process.

Scheduling and IT teams must also have the updated credentialing information. A teleradiologist may have access to the PACS of a hospital where credentialing for that hospital is still pending. The worklist should include only the site and the procedures the physician is authorized to read. For Interventional Radiology, confirmation of the approved procedures and the billing location for those services must be verified.

A remote reader may already cover one community hospital, and then cover a second hospital for weekend calls. The second hospital may rely on the distant site’s credentialing under a qualifying agreement, but it must also approve the physician’s privileges. Medical Credentialing Services can assist with the review of the physician’s license, the scope of service, IT worklist, payer affiliation and approval for coverage. The approval granted by the first hospital is not transferable to the second hospital.

The credentialing process, from intake to billing

• Determine what will be billed. List the radiologists, legal entities, payer products, sites, and components of each claim. Flag new enrollments, additions to existing groups, new facility sites, and work owned by the hospital.
• Obtain supporting documents. Request the most recent copies of state licenses, specialty training and board information, malpractice information, work history, and references. For organizational applications, request Articles of Incorporation, tax information, physical address and site information, and accreditation records. Use a secure channel to transmit documents containing sensitive identifiers.
• After reconciliation of the source records, compare the applicant information to NPPES, CAQH profile, PECOS, payer files, and billing setup. Address differences that affect the application. A correspondence address and a service address may legitimately differ, and in that case, the type of address should be annotated.
• Complete and submit the appropriate forms and follow-up on them. Work on eligible payer, facility, and hospital files concurrently, if the prerequisites allow. Obtain receipts or case numbers for all submissions. Assign a named owner and deadline for each request for additional information.
• Check the approved scope. Obtain evidence of payer system loading, approval or contract notice, and effective date. Retain any communication from the contractor. For Medicare, also retain the contractor’s enrollment or reassignment confirmation.
• Forward the approved records to billing and supporting evidence. Release claim segments that have been approved and maintain a hold queue for unapproved segments. Check the initial remittance advices (if available) for reasons the claim was denied.
• Assign a primary and backup owner for renewal of the approved records. Retain the application history and proof of activation. This allows the practice to reconstruct the history if a denial review is initiated.

A good status entry would look like:

Commercial PPO | Reader A | Group A | Site 1 | professional interpretation | confirmed participation from the payer’s effective date | Site 2 pending. Store the payer’s written confirmation or the portal record with the entry. If a representative confirms loading by phone, note the confirmation number and request written confirmation in the future. A directory listing may help clarify a discrepancy. Billing needs documentation that supports the product, claim unit, and relevant service time.

Compare eligible claims in your billing system with approved claims in your billing system with approved claims on your first batch. Review rendering and billing identifiers, location reported on the claim, and payer product selected. Acceptance by the clearinghouse only indicates that the claim was accepted by the clearinghouse for transmission. The first payer remittance gives you an opportunity to identify an unexpected out-of-network payment or a missing provider record before the same happens to a larger batch.