Medical Credentialing is the process of requesting to participate in a health insurance provider network – or to be contracted with the insurer. Healthcare providers have to apply to and must be accepted by the insurance company. It is necessary to qualify for benefits and to be associated with or a “network provider” for that insurance carrier.
CAQH ID help in credentialing and payer re-credentialing as well since payer uses this ID to export your application into their system directly.
The application process for credentialing is a very involved process that requires a lot of detailed information on the provider such as where they received training and education, background and experience, etc. The processing of applying can be time-consuming and quite involved. Each insurance carrier’s application process is different.
Council for Affordable Quality Healthcare, Inc. (CAQH) is a non-profit organization. Almost every person who’s been in the medical field is bound to have heard about CAQH. However, hearing about it and understanding what it does are two different things. There are still a lot of misconceptions about CAQH, what it is, what it does, and why it’s used. We’re going to answer these questions.
CAQH ProView is the healthcare sector’s leading resource for self-reporting professional and practice information to health plans and other healthcare firms.
Use of CAQH
CAQH has gone through several iterations over the years but its core service remains the same. They essentially function as a giant database that insurance companies and credentialing companies can pay to access. CAQH does not submit applications to insurance companies or complete the credentialing process for you but they do play a vital role in this process. Think about malpractice policy (COI), DEA certificate, your license, or anything else that regularly expires without your intervention.
The insurance companies needed these documents, and rather than providing each payer an updated license, you can upload this document into CAQH, attest to its accuracy, and grant the payers permission to access the file by using CAQH ID. Not all plans have access to CAQH so it’s important to not assume all payers will have your information once your profile is built. Most local/regional health plans lack access to it and none of the government payers use it.
When is CAQH used?
CAQH is used for initial credentialing and payer re-credentialing. This means that it’s not a set it and forget it database but requires maintenance on your part. When you’re first getting credentialed with health plans, some times payers will use your CAQH application/profile and export it into their system. To accomplish this, the payer has to be authorized and will often request your CAQH ID number over the phone, online, or via email.
Once you’re up and running which includes getting contracted (CAQH is not involved in this process) the payer will likely use CAQH ID to keep your file up to date. This is why remembering to re-attest every 90 days and keep your documents updated is so important.
Why register with CAQH?
Most of the insurance companies required CAQH. There are exceptions to this as a handful of states have their system which functions much like CAQH. However, even if your state has its system(which is rare), it still makes sense to register with CAQH as some of the national plans reluctantly use the state system but ultimately prefer CAQH.
Apart from being a requirement in many states, it improves efficiency by reducing the number of redundant requests or applications for information that have to be handled. There’s no cost for physicians and other health care providers to use CAQH ProView to create an accurate, comprehensive profile.
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