In November 2021, Kareo and PatientPop joined together to create Tebra. The website of Kareo now directs to Tebra. Kareo medical billing services include eligibility verification, claim scrubbing, electronic submission, ERA posting, patient payments, and an A/R dashboard. Practices can choose in-house or outsourced billing, depending on their needs. We cover the billing workflow at Kareo, challenges faced, and confirmation needed before outsourcing billing.
Before starting the University of Pittsburgh Medical Center (UPMC) NY credentialing guide, it is integral to understand a few things.
First, UPMC wears two hats. That is, it is a health insurance company (UPMC Health Plan) as well as a health system that credentials providers through its Credentials Verification Office (CVO).
Since this guide is specifically for New York providers, we must discuss UPMC’s positioning in the state head-on to prevent confusion later. So, continue reading!
Understanding the UPMC Positioning in New York State
UPMC is fundamentally a Pennsylvania-based company, and UPMC Health Plan (insurance payer) is only available in Pennsylvania and some selected parts of Maryland and West Virginia.
However, it does have a hospital in Jamestown, NY, i.e., UPMC Chautauqua. This hospital is in-network with most Highmark commercial, Freedom Blue, and Security Blue Medicare Advantage members through the Blue Card program.
Simply put, healthcare providers who want to render care services at UPMC Chautauqua in New York can apply for credentialing through the facility.
UPMC Health Plan NY Provider Enrollment & Credentialing Requirements
The table below offers an at-a-glance view of the key UPMC NY credentialing requirements:
| What Is Needed? | Description |
|---|---|
| CAQH ProView Profile | UPMC requires your CAQH Provider ID with authorized access to retrieve your initial credentialing application before you can complete the rest of the form. If you are a PA, CNM, or CRNP, you must attach a copy of the collaborative agreement to the application documentation. |
| UPMC Health Plan Provider Online | Complete your initial application and documentation submission using the UPMC Health Plan Provider Online secure portal. It is a digital repository that UPMC CVO uses for primary source verification. |
| Active NY State Medical License | You must have an active New York State medical license with no pending disciplinary actions. |
| DEA & CDS Registration | Current, valid Controlled Dangerous Substance (CDS) and Drug Enforcement Administration (DEA) registrations are mandatory if you want to legally prescribe controlled substances in the state. |
| Board Certifications | You must provide board certifications to verify your highest level of medical education, completed residency or fellowship programs, and active board certification status. |
| 5-Year Work History | Your resume must cover your previous 5 years of experience in MM/YY format. Also, explain any work gaps that exceed 6 months. |
| Hospital Privileges & Coverage Plans | Submit proof of active hospital admitting privileges at a network facility or a formal written arrangement for 24/7 coverage by an in-network admitting provider to ensure successful credentialing with UPMC NY. |
| Liability Insurance | Attach a certificate of current professional liability insurance demonstrating adequate coverage limits. |
| Malpractice History | Provide a detailed explanation of past or pending malpractice claims, sanctions, or license limitations, along with National Practitioner Data Bank (NPDB) query disclosure. |
| W-9 Form, NPI & Tax ID | You must provide active Type 1 (Individual) and/or Type 2 (Group) NPI, with an official W-9 form and IRS Tax Identification Number (TIN) letter. |
| Disclosure | Mandatory disclosure forms that identify entities and individuals with direct or indirect ownership or controlling interest in the practice. |
| Delegated Credentialing Agreement | A formal delegated credentialing contract permitting internal credentialing subject to UPMC oversight, periodic audits, and NCQA standards (if applicable). |
NY State UPMC Health Plan Credentialing Application Guidelines
Getting credentialed with UPMC NY does not have to be exhausting. Implement the following best practices to ensure a smooth application process:
1. Focus on Maintaining Your CAQH ProView Profile
UPMC requires you to review, update, and re-attest your provider profile directly every 90 days. The information that you must check and update frequently includes:
- Your complete street address.
- Office hours.
- Phone number.
- Ability to accept new patients.
- Telehealth availability.
- Hospital privileges.
- Any other information that affects your availability to the UPMC NY members.
Besides, if you are applying for credentialing with UPMC NY for the first time, do not forget to grant global access to the payer.
2. Reconcile Your Licensing & Practice Location Data
If you are applying for UPMC NY provider credentialing, take the time to reconcile your NY State medical license, active DEA and CDS registrations, and taxonomy codes across CAQH profiles, the UPMC Health Plan Practitioner Online portal, and the NPPES registry.
The reason? Mismatches in your data across these platforms can lead to immediate application rejection.
3. Initiate the UPMC NY Credentialing Process Early
On average, it takes 90-120 days for the UPMC NY credentialing process to complete. Therefore, you should start the UPMC Health Plan credentialing process at least 90 days before you plan to render services to its members.
Additionally, UPMC charges $100 from physicians, dentists, or podiatrists, and $75 from all other care practitioners for initial application CVO processing.
4. Synchronize Hospital Privileges & Coverage Arrangements
Ensure that your common privilege request form has active admitting privileges at a UPMC-affiliated network facility or a formalized, written coverage agreement with an in-network peer.
Bonus Tip: Outsource UPMC NY insurance credentialing services to professionals at NeuraBill.
Challenges in Getting Credentialed with UPMC Health Plan in NY
The following are some of the key challenges providers encounter while getting credentialed with UPMC NY:
- UPMC CVO relies on CAQH data to perform primary source verification. This means that if the information available on the CAQH profile is outdated, or the applying provider fails to grant access, it may freeze the UPMC NY credentialing application immediately.
- UPMC enforces rigorous requirements for active hospital admitting privileges for specialists and facility-based healthcare practitioners. Thus, if a clinician fails to maintain direct privileges at a UPMC network-approved facility or does not have a formal written 24/7 coverage agreement with an in-network peer, the credentialing application can stall.
- Healthcare providers often confuse credentialing and enrollment. Credentialing is the prerequisite for becoming an in-network provider. Enrollment involves system setup, fee schedule configuration, and payer ID mapping.
- Thus, if a clinician starts billing UPMC soon after passing clinical credentialing without signing the contract with an effective date, it will result in automated denials and lost revenue.
Streamline UPMC NY Credentialing
To summarize, UPMC does not provide health insurance services in New York State. However, they do have a hospital in Jamestown, NY, named UPMC Chautauqua.
Therefore, if any healthcare provider wants to render services at UPMC Chautauqua, they must apply for UPMC NY credentialing through the website.
Similar to Pennsylvania providers, New York providers must also have an updated CAQH ProView profile that was attested within the last 90 days. The only distinction is the medical license; i.e., New York providers must have an active New York State medical license, as the services will be provided in NY.
