What is the Insurance Credentialing Process?

Credentialing is a process that the insurance companies use to verify your education, training, and professional experience and to ensure that you meet their internal requirements for serving as an in-network provider on their panel. The goal of the insurance credentialing process is to become in-network and prevent your patients from having claims go towards their out-of-network deductible.

The process of credentialing with an insurance network actually consists of two phases- Credentialing and Contracting.  The contracting phase is where the company issues you a participating provider agreement that defines the terms of participation for receiving in-network reimbursement for your claims. Without a participating provider agreement, you will not receive in-network reimbursement.  Until your credentialing and contracting are complete you may have the option to bill the network as an out-of-network provider, but there is no guarantee of your claim being processed.  Government health plans such as Medicare and Medicaid will not pay for any out-of-network services.

Checklist items for credentialing and contracting preparation:

  • Establish a business entity under which to practice (LLC, S-Corp, PC, etc) and obtain your tax ID
  • If operating as a sole proprietor, consider obtaining a federal tax ID to operate under instead of your SSN
  • Obtain your professional liability insurance policy
  • Obtain an NPI number for you individually (type 1) and your business entity (type 2)
  • Be fully licensed in the state where you will provide services (including prescriptive authority)
  • Create a profile with CAQH and keep it current
  • Have your practice location ready
  • Know which insurance networks you want to participate with

Out of so many insurance companies which insurance to credential with is the most common question we receive? You can ask a peer in practice in your area or an office manager who handles billing in your area what insurance companies provide the most patient base in your area.  Their practical knowledge of local insurance companies can be valuable.  Major national plans to consider include Aetna, Blue Cross Blue Shield, Cigna, United Healthcare, Humana, Medicare, and Medicaid.  There are many Medicare Advantage plans as well as managed Medicaid plans for consideration as well.  There are also some major national PPO plans that rent their network such as Multiplan that can be important in certain areas.

The general process of credentialing:

  • Contact the network provider services department to inquire about their credentialing process and obtain a credentialing application. Most plans have applications and information on their website such as here with Aetna
  • Take time to fully complete your application listing all service locations for your practice, sign and date your application, and include copies of all required documents
  • Ensure that your CAQH profile is up to date with all information particularly practice location information and includes copies of all required documents such as license, insurance, board certifications
  • Verify with the insurance company that your credentialing application was received, and follow up with the insurance network on a regular basis until your credentialing is complete and you have a network effective date with a participating provider agreement
  • Respond to any requests for additional information that the insurance company may have
  • Document all of your follow up activities as you go through the credentialing process
  • Review your participating provider contract for details of your requirements as a network provider, claims submission procedures, fee schedule for your services, timely filing limits, and all other important contract terms
  • Keep copies of all credentialing applications and contracts submitted. Be sure to retain a final copy of your network contract

When your credentialing process is complete, you are ready to begin billing the network for services.

Here are a few key things to remember about maintaining your credentials:

  • Access the network website so that you can confirm you are listed in their directory. Most networks also have access to claims filing, benefits verification, claims follow-up, and other revenue cycle activities on their website
  • Record all contact information for the insurance company related to claims filing, contracting, and credentialing
  • Record your provider id, effective date and when your next re-credentialing process will be due
  • Maintain copies of all your network contacts in one central location for ease of management
  • After a year of service, evaluate which networks are providing patient volume and compare reimbursements to identify carriers to eliminate or renegotiate reimbursement rates
  • Maintain your CAQH profile by quarterly attestations and document updates any time you renew items such as license or malpractice insurance
  • Maintain your NPPES records so that your NPI numbers always reflect the accurate name, address, and other information
  • Do not neglect re-credentialing requests from plans or requests for renewed or additional documents. Failing to respond to a request can lead to the network termination

Confused about the insurance credentialing process? Well, just wait until you actually start the process. Fortunately, if you’d rather delegate this task to someone else, you can! You can delegate it to us. If a provider is trying to run their private practice and be credentialed at the same time, it can overwhelm them to the extent that they are missing deadlines for the applications, or missing appointments filling out applications.

Our credentialing specialists will use their education, training, and experience to get the job done for you so that you can focus on providing your customers with quality healthcare. To hear more about our services, you can reach us at 888-357-3226 or visit drop a mail at info@medicalbillersandcoders.com to find out additional information.