To bill, any healthcare service to an insurance carrier, the provider, or the health organization should be credentialed by that insurance carrier. Provider credentialing is one of the most important processes of practice management. In provider credentialing, you are enrolled in the insurance carrier’s network and get authorized to render services to the patients who have enrolled with the insurance carrier. Physician credentialing is the process of validating the provider’s professional records including qualifications, experience, certifications, license, and other records. Credentialing Procedure in healthcare is the process by which medical organizations verify the credentials of healthcare providers to ensure they have the required licenses, certifications, and skills to properly care for patients. Most providers are under impression that credentialing is a one-time process but it’s not, credentialing will happen in the following scenarios:
- Initial credentialing when a healthcare provider joins a practice or starts his own practice
- When a physician moves from one practice group to another
- When a physician or a health care provider enrolls with a new insurance carrier
- Recredentialing to maintain their credentials
With an exhaustive list of information to be collected, submitted, and verified, credentialing is a tedious and lengthy process and may usually take about 2 to 4 months to get credentialed. Sometimes, it may even get delayed by 6 months when documentation is not done completely, and the file goes back and forth as well as processing delays from the insurance end.
Credentialing Procedure for Adding New Provider
Step by step credentialing procedure for adding a new provider to your current healthcare practice is as follows:
- Provide an updated and attested CAQH profile, with new practice affiliation (including start date) listed. Additionally, the provider’s license and DEA must also be updated with the new state they’ll be working in if this is different from their initial affiliation.
- Provide a list of payers they are currently affiliated with, including commercial, Medicare Advantage, Medicaid HMOs, worker’s compensation, Tricare, as well as any TPAs.
- Provider tax ID to insurance carriers and update your CAQH profile with this information as well.
- As hospital credentialing is necessary for some insurance payers or specialty providers, the list of hospitals you intend to have privileges with will need to be updated in your CAQH profile. If you don’t intend on having hospital privileges for your practice, you will need to create an admitting arrangement with a provider or decide which hospitalist or ER in your area you will be utilizing for admitting arrangements.
- Provide new or updated malpractice policy and update in your CAQH profile.
- Provide the group’s primary billing type, which will be listed on applications with a Tax ID.
- Provide the group’s Medicare PTAN that you plan to be included on, which will be listed on your Medicare application linked to the new group.
Required Documents
Following we have provided a comprehensive list of documents required for provider credentialing. Some of the documents may not be required for adding a new provider to existing practice.
- Required Provider Details/Documents: Name (exact name as in records); Known by any other names; Gender; Date of Birth; Age; Ethnicity; Citizenship Information (Permanent Resident Card, Green Card or visa status (if applicable); e-mail Address; Mailing Address; Contact Number; Recent photograph signed and dated in the margin; Updated Curriculum Vitae (with complete professional; history in chronological order and no gaps, exact beginning, and end dates to be mentioned); Social Security Number; Current CME Documents; Educational qualification (to include month and year of attendance, institution name and address, program director name, and degrees attained, diploma, training certificates); Copy of current Board Certificate, including the name of issuing board and dates of board certification/recertification; Copy of current active state licenses; All previous, current, and pending hospital affiliations; Copy of Professional Liability Insurance Coverage (for the past 10 years with complete details); Malpractices Policy document; Any malpractices history, if any, with complete details; Any disciplinary actions, if any, with detailed explanation; Military discharge record- Form DD-214, if applicable; Peer References/Recommendations with assessment of your clinical competence and date and year mentioned; Completed Delineation of Privileges Form
- Practice Details: Practice Address; Practice Tax Id; Practice Contact Number; Practice Fax Number; Business License of the Medical Practice; Various insurance coverage details of the Medical Practice; Copy of National Provider Identifier Number (NPI No.); CAQH id; PECOS id; Medicaid details; Current Federal DEA; Copy of current State Controlled Substance Registrations or certificate(s); UPON number.
Provider credentialing can be a long and complicated process due to legal and regulatory requirements, but it’s a worthwhile investment for your providers, your practice. MedicalBillersandCoders (MBC) saves you time and money by making your credentialing process much more efficient. Our credentialing experts work behind the scenes to help you follow best practices in provider credentialing. Contact us today to learn how we can expedite the provider credentialing process for you.
FAQs
Q: What is provider credentialing?
A: Provider credentialing is the process by which healthcare providers are verified and enrolled with insurance carriers to ensure they meet the necessary qualifications, licenses, and certifications to provide services to patients.
Q: Why is credentialing important for healthcare providers?
A: Credentialing is important because it ensures that healthcare providers meet the necessary standards to practice, and it allows them to bill insurance carriers for services rendered to patients.
Q: Is provider credentialing a one-time process?
A: No, credentialing is not a one-time process. It occurs when a provider joins a new practice, enrolls with a new insurance carrier, or moves to a new state, and regular recredentialing is required to maintain credentials.
Q: How long does the credentialing process take?
A: The credentialing process typically takes 2 to 4 months but can sometimes be delayed up to 6 months due to incomplete documentation or processing delays from the insurance side.
Q: What documents are required for provider credentialing?
A: Commonly required documents include the provider’s license, certifications, professional history, malpractice policy, educational qualifications, hospital affiliations, and tax identification details.
Q: Can Medical Billers and Coders (MBC) help with provider credentialing?
A: Yes, MBC offers credentialing services that streamline the process, saving time and money by ensuring all necessary steps and documentation are handled efficiently.
Q: What is CAQH, and why is it important in credentialing?
A: CAQH (Council for Affordable Quality Healthcare) is a system used to manage and update provider credentials. An updated CAQH profile is required for provider credentialing with insurance carriers.
