Basics of Provider Credentialing and Contracting

Credentialing is a process where insurance companies verify your education, professional experience, and training. For insurance companies, credentialing ensures that you meet their internal requirements for serving as an in-network provider. Insurance companies have web-based provider directories where they list all in-network providers for their plans. Such updated provider directories are regularly used by healthcare services consumers to locate physicians and other healthcare providers who accept their insurance. Once you complete the credentialing process, consumers can locate you as an in-network provider in their panel for your specialty. The process of ‘credentialing’ or ‘provider enrollment’ with an insurance network actually consists of two phases i.e. Credentialing and Contracting. As mentioned earlier, for credentialing, any insurance company will verify all your credentials and will make sure that you meet the requirements for participating in the network. While contracting phase is where they issue you a participating provider agreement that defines the terms of participation for receiving in-network reimbursement.

Till the time your credentialing and contracting are in process, you can bill the insurance company as an out-of-network provider, but there is no guarantee of your claim being processed. Out-of-network reimbursement depends upon the patient’s policy and out-of-network benefits. Medicare and Medicaid will not pay for any out-of-network services for any specialty.

Provider Credentialing and Contracting

Provider credentialing (primary source verification) is nothing but a background check on the physician by the insurance company. This background check includes verifying the provider’s education, legal authorization, and competencies to practice medicine. The Credentialing process starts with submitting a participation request i.e. filling the application form. Such a participation request varies from the unique credentialing application, CAQH, or acceptance of a state standardized credentialing application.

After receiving a provider enrollment application, they perform a thorough credentials verification of the provider and ensure he/she meets credentialing requirements. You can expect the credentialing process to take up to 90 days. The first phase is getting your application approved by the credentialing committee, then the second phase i.e. contracting begins.

Most of the time, insurance companies have staff dedicated to the contracting process and are separate from the credentialing department. While contracting, you can negotiate reimbursement rates and can review the language of the contract, and all responsibilities of participation. You can negotiate if the company’s standard reimbursement rates don’t meet your expectations.

Once your credentialing agreement is signed and returned back to the network, you will be given a provider number and an effective date and you can begin billing the plan and can receive ‘in-network reimbursement for your claims. Generally, you can expect networks to take 30-45 days for this process.

Medicare, Medicaid, and Tricare

Credentialing in government health programs like Medicare, Medicaid, Tricare is a bit different. These government health programs have standard forms that must be filled out and sent to the appropriate authority that handles all the administrative functions. Medicare and Medicaid will review your application against strict enrollment standards.

You can find helpful enrollment information on the CMS website regarding the Medicare Provider Enrollment process. It is always beneficial to have someone experienced in such government health program enrollment who reviews your application prior to submitting it.

Getting yourself credentialed can be tedious, cumbersome, time-consuming, and sometimes frustrating. Trying to navigate the credentialing process is overwhelming and often costs more time and money than working with a professional who can advocate on behalf of the provider.

Oftentimes, providers are too busy healing patients and handling the administrative needs of their practice. They don’t have enough time to complete credentialing applications and follow-ups. Medical Billers and Coders (MBC) handles everything from contracting and credentialing to medical billing. Contact us to learn more.