AddVal, Inc. | Unrivaled Medical Credentialing Expertise!

Will the Claim be Paid? Effective Date – When & How is it Determined?

For new practices & new physicians joining existing practices, a pressing question is always – “When can we see patients?” Unfortunately, there is not one, standard answer to this question. Medicare will issue the PTAN or link the PTAN to your practice using either the effective date you request or the date they receive the forms – whichever is later. (Please remember that any submissions more than thirty (30) days before the start date are rejected!) Once the PTAN is issued or the link to your practice is complete, claims can be processed. This will present a cash flow issue until the PTAN is done, but, you are safe in knowing that the Medicare claims will be paid.

The commercial plans, on the other hand, will assign the effective date based on the date of the contract execution or the date the physician is linked to your group contract. The unpredictability of the effective date is especially distressing for new practices & new physicians joining group practices. It is a business decision related to seeing patients prior to the credentialing & contracting being completed for the commercial payers. If you are growing a new practice, it may be ‘good business’ to see the commercial patients before the credentialing & contracting is done and view this as an investment in your practice because the commercial payers will either pay you nothing or out-of-network rates. Or, you can wait to schedule patients for the commercial insurers once the credentialing & contracting is done.

Be sure to refer to the monthly tracking report for the effective date for each insurer! As always, consult the member’s ID card to determine which insurer is processing the claim.

Name Changes

At least monthly, we discover that one of our clients changed their name – either through divorce or marriage. This discovery usually happens when the credentialing is stopped because the insurer verifies the physician’s license only to discover the name on the license is not the same as the name on the credentialing documents. Please be sure to make your physicians aware that any changes to their name on their license must be accompanied with the same name change to their DEA, CDS and malpractice insurance. The CV should also be updated with the name change!

Be sure to notify AddVal regarding any name changes so we can assist your physicians through the processes. Don’t wait until claims are denied!


Remember:
“Both optimists and pessimists contribute to our society. The optimist invents the airplane the pessimist the parachute.” --Gail Stern

If you need any help with Medicare credentialing or credentialing with any commercial insurers, or you are concerned about Medicare Revalidation please contact AddVal for assistance at 215-396-8972, mmcfarla@addvalinc.com.

About Add Val, Inc.
AddVal, Inc., based in Southampton, PA, currently serves over 5,000 clients across the U.S., providing experienced medical credentialing services. The company employs a unique blend of talented individuals experienced in clinical administration, healthcare insurance and medical credentialing. This team, combined with a singular focus on credentialing, produces unrivaled results for clients.

AddVal, Inc

Unrivaled Medical Credentialing Expertise
AddVal, Inc.
607 Lakeside Park
Southampton, PA 18966

Telephone: 215-396-8972    |    Fax: 215-364-2187    |    Email: mmcfarla@addvalinc.com