Provider Data Maintenance

Enrollment is the process used to add a practitioner or facility to establish participation under any currently contracted network.

Network Examples:

• Ambetter - Exchange NV, and NVBBSP
• SilverSummit - Medicaid NV
• Wellcare - Medicare

Enrollment activities may include:

• Adding practitioners to existing contracted groups
• Adding a new service location
• Specialty changes to existing practitioner
• Credentialing updates

Enrollment requests require complete and accurate information to ensure providers can be properly loaded into SilverSummit's systems.

Credentialing is the process of verifying a provider's qualifications and eligibility to participate in the network.

Credentialing reviews may include verification of:

• Licensure
• Education and training
• Board certification (when applicable)
• Professional work history
• Sanctions and exclusions
• Malpractice history
• Practice specialty
• CAQH information
• Physician and mid-level taxonomies in NV require Hospital Privileges or Admitting Arrangements for Credentialing.
  • If the provider does not have hospital privileges, admitting arrangements can be documented as a statement explaining what would happen in the event of an emergency.
    • For example: “The office will call 911” or “Patients will be referred to the nearest hospital or urgent care facility.”

✅ CAQH should be current and attested within the last six (6) months.

✅ SilverSummit must have access to the provider's CAQH profile.

✅ Taxonomy and specialty information should match state licensure and NPPES records.

✅ Hospital Privileges or Admitting Arrangements, if applicable.

For Medicaid, the NPI must be registered with the State in order to be enrolled/credentialed. Credentialing will be completed by Verisys.

Please be on the lookout for any correspondence from them for any required additional information to avoid credentialing delays.

Contact Information for Verisys for Providers - Phone (855 )743-6161 or email outreachsupport@verisys.com.

• Completed Practitioner Data  Form (PDF)
  • If adding multiple practitioners, please reach out to NVSS_ProviderQuality@silversummithealthplan.com for a Blank Roster.
• Attested CAQH
  • If there is no CAQH and the specialty requires credentialing, a completed Credentialing Application (PDF) should be submitted.
• Current W9

Enrollments requests should be submitted via the PDQ Requests or via email NVSS_ProviderQuality@silversummithealthplan.com with the completed required documents.

A demographic update is any change to information already maintained within SilverSummit Healthplan's provider systems.

Examples include:

• Practice name changes
• Address updates
• Phone number updates
• Panel updates
• Directory updates
• Office hour changes
• Languages spoken
• Billing Address updates
• Practitioner name changes

To avoid delays, please include:

Practitioner and Group Information

• Practitioner name
• Practitioner NPI
• Tax ID (TIN)
• Group NPI
• Group name (if applicable)

Existing Information

• Current information on file

New Information

• Updated information
• Effective date of the change

Supporting Documentation

When applicable:

• Completed Data Form or Roster
• W-9
• Other supporting documents

*For location updates with multiple practitioners, please include a completed roster with the request.

Data Maintenance requests should be submitted via the PDQ Requests or via email NVSS_ProviderQuality@silversummithealthplan.com with the completed required documents.

Providers should notify SilverSummit Healthplan as soon as they become aware of:

• Retirement
• Practice closure
• Relocation outside the service area
• Provider death
• Voluntary network departure
• Group disaffiliation
• Changes impacting member access

Early notification helps:

• Protect member continuity of care
• Maintain provider directory accuracy
• Prevent claims processing issues
• Facilitate member communication when necessary

Practitioner Information

• Practitioner name
• Practitioner NPI
• Group name (if applicable)
• Tax ID (TIN)
• Group NPI

Termination Details

• Requested termination date
• Reason for termination
• Affected locations
• How we can access Medical Records

Member Transition Information

If applicable:

• Coverage arrangements.
• If Primary Care Provider
  • Where should members be reassigned to? Please provide Practitioner Name and NPI to move members to.
    

Termination requests should be submitted via the PDQ Requests or via email at NVSS_ProviderQuality@silversummithealthplan.com with the completed required documents.