Provider Credentialing - Overview and Checklist

Provider credentialing is important as it opens up new revenue opportunities like a credential provider gets an increased number of patients through referrals from payers. Moreover, credentialing ensures the patient that they are getting treatment from a credible provider.

What is Provider Credentialing?

Provider credentialing is a process in which a provider's qualifications and competency-based on demonstrated competence are formally assessed by a health insurance carrier. This process is time-consuming and takes up to three months to complete. The need for extensive background information submission is the main reason behind the lengthy process. Depending on the circumstances, the clinic or organization for which the provider is working may also need to go through credentialing.

Provider needs to satisfy the following criteria for credentialing:

  • Has an unrestricted license
  • Any disciplinary actions or sanctions by insurers, hospitals, licensing boards, or professional organizations
  • Presence of any criminal history
  • Is the Provider certified by the medical board?
  • General health status

If a physician meets standards for delivering clinical care then the credential process is validated and usually takes 60 -120 days for a payer to get credentialed.

While the process of credentialing is in process, some providers have doubts that "can they work during the Credentialing Process?”

The answer to the above question is "No”. A healthcare provider needs to wait for completion and approval of the credentialing process approved before they can begin to work.

This assures that every patient receives care from properly educated and experienced professionals at all times to treat their healthcare concerns.

It is a legal risk for any facility which allows non-credentialed individuals to work, even if they are in the process of getting their credentials.

Following are some checklist for accurate application of hurdle-free credentialing process:

  • Provider start date in practice
  • Copy of state license
  • Copy of DEA
  • Provider DOB and SSN
  • NPI Number
  • Updated CV- work history
  • NPPES logons
  • CAQH logons
  • Malpractice incidence details
  • Copy of Degree/Diploma certificates
  • Copy of Driving License
  • Group Name
  • GNPI & Tax id
  • Practice and billing address along with Phone and Fax #
  • Signed W-9 Form

Role of CAQH in Provider credentialing

The Center for Affordable Quality Healthcare, Inc. (CAQH) is one of the most frequently-used Web services for credentialing. CAQH offers an online database called the Universal Provider Data source (UPD) that collects all of the information required for credentialing and then makes it available to third-party payers.

There are three steps to getting set up in CAQH:

  • Obtain your CAQH ID (within 2-3 business days)
  • Set up your secure username and password
  • Complete the online application and send in the required documentation
  • Send your attestation for signature, which certifies the application
  • Grant insurance companies access to your online application

Not having a completed, up-to-date CAQH application will delay your enrollment with the insurance companies. Furthermore, this will prevent you from getting reimbursed for your services.

Generally, the process can take anywhere from several days to several weeks. It can vary depending on what field you seek credentials in, what CVO you are using, and whether you have provided all supporting documents and filled out the application correctly.

For this reason, it is normally best to begin the application process 90 days before your start date at a new facility. Ninety days allows for some margin in case verification entities do not promptly respond to requests or if the CVO must investigate discrepancies for clarification.

If you are looking for guidance and support for provider credentialing then you can outsource credentialing to a reliable and professional physician credentialing service provider like us.


Published By - Medical Billers and Coders
Published Date - May-17-2021 Back

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