AB2026-08-004 Reminders

REQUIREMENTS: By August 1, 2026 (IMMEDIATELY): - Billing team: Identify staff responsible for reviewing electronic claim files and ensure they have access to Availity Essentials → Capital Payer Space to retrieve weekly eCLD (Electronic Closed Letter Detail) files. Transition from monitoring USPS mail for closed-claim letters to checking Availity portal weekly. - Billing/Appeals team: Update appeal submission procedures to include only the specific member's information being appealed. Remove any processes that bundle family member or multi-member records into single submissions. Add checklist to appeal templates requiring date-of-service matching and single-member verification before submission. - Provider Relations/HR: Ensure all CAQH-credentialed providers are reminded to update their CAQH application every 120 days. Implement tracking system to flag providers approaching the 120-day deadline. Document re-attestation completion dates to prevent credentialing delays. - Network Development: For new graduate providers requesting network participation, verify completion of all post-graduate education and confirm admitting privileges at a participating hospital (except for anesthesiologists, allergists, emergency room physicians, dermatologists, pathologists, and radiologists) before approving network entry. CONSEQUENCES OF INACTION: - Failure to monitor eCLD files will result in missed claim reconciliation opportunities and delayed resubmissions. - Appeals containing unrelated member information will be delayed for resubmission and may create privacy/compliance concerns. - Failure to re-attest CAQH within 120 days will result in delays in credentialing, contracting, and network participation termination. - New graduates without admitting privileges (where required) will be denied network participation.