FAQ

For many healthcare practices, credentialing can be both confusing and overwhelming.

At Credentialing, we provide a full-service credentialing solution. Let us handle the complicated processes and the repeated follow up calls with insurance companies for you.

Listed below are answers to some of the most frequently asked questions about the credentialing process. Take some time and review the information below or simply call us at (855) 247-8482 with your questions, and we’ll be happy to help!

Being credentialed with insurance panels means that you are able to see patients who have specific insurance plans and bill those insurance companies directly for the services you render. This can greatly increase the number of patients who can access your services.

Yes. When you sign up for credentialing with us, you get to choose exactly which panels you want, and don’t want, to be credentialed with. Typically most outpatient physician providers credential with 7-8 payors, where as hospital based physicians (in-patient) usually credential with 10-15 payors (pretty much any patient with any insurance that comes to hospital). Physicians working in tristate area (border of 3 states) like in our physician owner practice credential with 25 payors.

Yes. When you sign up for credentialing with us, you get to choose exactly which panels you want, and don’t want, to be credentialed with. Typically most outpatient physician providers credential with 7-8 payors, where as hospital based physicians (in-patient) usually credential with 10-15 payors (pretty much any patient with any insurance that comes to hospital). Physicians working in tristate area (border of 3 states) like in our physician owner practice credential with 25 payors.

Most behavioural health providers, Therapists (PT, OT, ST, ABA etc) typically select 6-7 panels.

We can help! One of our credentialing specialists will talk with you by phone and can help you to select the panels in your area that will be the best fit for you and your practice.

The popularity of insurance companies varies depending on location. However, some of the most popular and largest insurance companies are Aetna, Cigna, Magellan, Tricare, United Healthcare, Humana, Value Options/Beacon Health Options, Medicare, and many others.

The amount of time that it takes to complete the credentialing process varies by license type. For a standard outpatient practice, the Credentialing Team will put in between 10 and 12 hours of work for each insurance panel. If an appeal has to be filed, that will add a minimum of 5 additional hours of work to that panel.

Facility-based services, Home Health Care Agencies, and DMEs will all take over 20 hours to complete the credentialing process.

You bet! We have credentialed literally thousands of providers across the United States, including providers as far off as Alaska and Hawaii. No matter where your practice is, we have the experience needed to get you credentialed.

We have credentialed healthcare providers of more types than we can list: from chiropractors to behavioral health providers to surgeons. If you are eligible to be credentialed, we can get you credentialed!

If you are providing a service that is new and innovative, we also offer research with the insurance companies to see if your specialty is eligible for credentialing. This can save you hours of headaches reaching out to the individual insurance panels.

If you are fully licensed, we should have no problem identifying plenty of insurance companies and third party payers for you to be credentialed with. In some areas, some panels can be very selective or closed. In these instances, we will talk with you about the likelihood of a successful medical credentialing process. We want you to get the most out of your medical credentialing investment, but we cannot guarantee that insurance panels will accept you.

Finding out a panel is closed can be frustrating. However, sometimes when panels say they are closed, they are still accepting providers, but on a limited basis. In the case of a panel saying that they are closed, we can and will submit an appeal when possible to the insurance company on your behalf. During an appeal, we will try to connect with the insurance company representative assigned to your area. We will then stress important parts of your qualifications and clinical practice. For instance, perhaps you have a specialty that the insurance company desires, or you are practicing in a neighborhood that is underserved. We do have success with many of our appeals. However, if a company is saying that their panel is closed, it might not be possible to get on the panel at that time.

This situation is extremely rare as most insurance panels are consistently looking for new providers to add to their network. If panels are closed we will submit a formal appeal on your behalf when possible and advocate for you with the insurance companies. During this appeal, we make a case as to why you are unique and why you should be allowed onto the panel. We have a very high success rate when it comes to appeal approvals.

Sometimes, but it is highly unlikely. We have had success with medical credentialing such providers on a limited basis—generally in areas that are very underserved. In most cases, insurance companies are looking to network exclusively with fully licensed healthcare providers. As an intern you can typically bill through a supervising provider.

If you are a fully licensed provider most insurance companies will accept you right away even if you don’t have years of experience in the field. There are some panels that have certain regulations and may require a specific amount of experience. Your Credentialing Specialist will be able to help you navigate these requirements when recommending panels.

Yes! Like insurance companies, EAPs are valuable third party payers to be credentialed with. The credentialing process is very similar to being credentialed with insurance companies. In fact, some of the major insurance companies also offer an EAP. Popular EAPs include: ComPsych, Optum, Magellan, Value Options, and Cigna.

We charge per panel, per provider that you apply to. We do not have any start up fees, hidden charges for your initial credentialing. You only pay for the work we do. Our pricing does vary by the type of credentialing you need. We have volume discounts if you enroll on more panels at a time. On the other hand pricing will be high if you enroll on only 1-2 panels initially. Call our Business Development Office at 855-247-8482 to get a quote.

CAQH stands for Council of Affordable and Quality Healthcare. It is a nonprofit that was created several years ago by the private insurance panels. Most commercial payers require that you have the CAQH profile completed before you begin the credentialing process. Panels use the CAQH to verify providers personal information as well as education and work history.

Proper credentialing with the insurance panels is instrumental for operating an insurance-based practice. In order to bill efficiently and effectively, providers must be credentialed with each panel that they wish to bill. If the medical credentialing is not correct, your claims to the insurance panels can be delayed or even denied.

A panel is usually the equivalent of an insurance company. The term is commonly used to refer to a panel of plans. This is demonstrative of the fact that when a provider is on a panel he or she can bill for all of the plans under that panel.

Your NPI is a National Provider Identifier. It is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).

The NPI 1 number identifies your license type, license level, and specialty. Panels require that you have your NPI 1 before you begin the credentialing process.

An NPI 1 identifies you as the rendering practitioner, or the one providing the service. It’s like your social security number within the medical community. It follows you for the duration of your career. Regardless of who set up your profile, this identifier is unique to you. You take it with you wherever you work.

An NPI 2 is an organization identifier. It identifies the place you are providing the service. If you work for an agency this would be your employer’s company name and information. If you are in private practice this would be in your business name.

We recommend that anyone whose business has a tax ID acquire an NPI 2. From a credentialing perspective, this allows your contract with insurance panels to be at the organization level for applicable panels. Then your NPI 1 is linked to the NPI 2 for billing purposes. Therefore, your business is paid for your services. This becomes especially important as you grow your business and your team.

Additionally, some insurance panels like Medicaid, Medicare, and BCBS require the NPI 2 in order to credential with them if your business has a tax ID.

Credentialing happens before a provider is considered eligible to participate in an insurance network. Recredentialing is done every 1-3 years after the original effective date of the provider to make sure that all of the information listed with the insurance panel are up to date and accurate.

The National Committee on Quality Assurance (NCQA) sets the credentialing standards and the specific state and federal regulations when it comes to Medicaid and Medicare participation.

Many insurance panels will take the information from your CAQH profile in order to initiate the process. If a provider submits an application on the website for the respective panel, the application will go through the process and the panel will typically access your CAQH profile to verify the information on your application.

Almost all insurance panels will require providers to have or obtain a CAQH ID. If you don’t already have one, we are able to create one for you! Let your specialist know that you’d like to have us complete an application for you and we’d be happy to add it to your project. Otherwise, please visit CAQH ProView to start the process.

Unfortunately, we cannot guarantee that a provider will be accepting into the network as that power lies with the insurance panel. However, if you are not approved for participation, we will either follow through with an appeals process (if the panel has one) or we will wait until the next quarter to submit a new application.

You bet! We have credentialed literally thousands of providers across the United States, including providers as far off as Alaska and Hawaii. No matter where your practice is, we have the experience needed to get you credentialed.

We have credentialed healthcare providers of more types than we can list: from chiropractors, to behavioral health providers, to surgeons. If you are eligible to be credentialed, we can get you credentialed!

Good question! When we use the term “panel,” we are using an abbreviation for insurance panel, which is the group of doctors who are networked with the insurance company and are able to provide services for patients that have that insurance. A panel could also be an EAP Panel, which is the same thing, but with an EAP (Employee Assistance Program).

Yes, we offer complete revenue cycle management services. To learn more please call +1-855-247-8482 or visit the medical billing section in our website.

Healthcare providers need to be credentialed at least every three years. Some healthcare facilities or insurance companies perform recredentialing even more often.

Facilitate practice by physicians and others in the hospital or healthcare system. Under federal and state laws and regulations.

You should have the following data before you start the credentialing business.

Obtain a Tax ID from the IRS under the legal business name.Register for a Type 2 National Provider Identifier (NPI) and also Type 1 NPI.Register for a bank account under the legal business name.Search for a location to open your practice.Obtain Malpractice Insurance.Speak with our Credentialing Department to start the credentialing and contracting process

  • The following steps work to get physicians credentialed with insurance.

     

The companion piece to credentialing is “privileging,” which is the process of authorizing a licensed or certified healthcare practitioner’s specific scope of patient care services. Privileging is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance.

Credentials Verification Organization (CVO) Accreditation ensures a meaningful, rigorous, and fair credentialing process that protects both patients and providers from poor credentialing practices.

Credentialing is the process obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications.

The provider needs to obtain an NPI and then register with CAQH. Submit an online application to Aetna with all supporting documents. Allow 30-60 business days to complete the credentialing process.

Every four months, you will receive a request from CAQH to re-attest that all of the information in your application is correct.

Provider Enrollment (or Payor Enrollment) refers to the process of applying to health insurance networks for inclusion in their provider panels. The Contracting phase of enrollment is when the provider has been approved by Credentialing and is extended a contract for participation.

The nurse practitioners credentialing process involves the verification of education, licensure, certification, and reference checks. In order for a nurse practitioner to be eligible to bill government agencies and other commercial insurance companies, they must be credentialed. Initial credentialing involves a lot of paperwork.

Credentials Verification Organization (CVO) Accreditation ensures a meaningful, rigorous, and fair credentialing process that protects both patients and providers from poor credentialing practices.

Yes, if you want to get all in-network payment benefits with insurance providers.

No, if you do all private pay and take NO insurance.

Vendor credentialing is the process by which companies and facilities ensure that the vendors they work with have the appropriate background and training to access their facilities.

Council for Affordable Quality Healthcare (CAQH), a not-for-profit alliance of the nation’s leading health care plans and networks, has developed a single credentialing application and common application database. Instead of having to submit separate applications to each managed care organization, physicians can use the Universal Credentialing Data source system to submit a “universal” credentialing application either electronically or in hard-copy format.

No, one provider has a single National Provider Identifier (NPI). Under a few circumstances group may have two NPI2. Because of multiple locations for the practice.

Delegated Credentialing is done when groups are large enough (such as hospitals or universities) the payors can grant an addendum to a contract allowing the group to maintain their own credentialing. This saves time since the payors can be inundated with applications and get backlogged. With delegated credentialing, the group or it’s contracted company are responsible for completing the primary source verification process typically performed by the insurance company. It’s the responsibility of the delegated entity to ensure that all providers meet the standards as set forth by the insurance company. Once the provider is credentialed at the facility (such as a hospital) the entity would send each delegated payer a roster (typically once a month) showing all employed providers and any new additions since the last report.

Physicians and other healthcare practitioners such as a hospital, a counseling office, chiropractor, Dentist, Physical Therapist, Occupational Therapist, an optometrist’s office, Urgent care, Treatment center, Social worker etc, who wish to bill an insurance company as an in-network provider must undergo a process of credentialing.

Once a provider is credentialed with an insurance company, they can bill that company directly. In addition, most insurance panels will also provide “in-network” providers with referrals and preferential reimbursement rates. Many panels split the credentialing process into two parts. There is a credentialing phase and a contracting phase. During the credentialing phase, an insurance panel will perform primary source verification on a provider to make sure that the provider meets the minimum requirements of the panel. In addition, the panels may access the CAQH to assess the providers' education and employment history.

Once the credentialing phase is complete, the provider’s application will be sent to contracting. At this time, the provider and the practice may be offered an “in-network” contract with the panel. If they are offered a contract, it will usually include the fee schedule and CPT codes for which the provider is eligible to bill.

At Credentialing.com, we use the term credentialing to encompass both credentialing and contracting phases of the credentialing process. The credentialing specialists are trained to navigate both credentialing and contracting to ensure providers are properly on the panels.

https://www.credentialing.com/what-is-insurance-credentialing/