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Understanding Provider Credentialing Process


When any healthcare organization hires a new physician, nurse practitioner, or another healthcare service provider, it’s essential to move them through the medical credentialing process. Provider credentialing allows you to verify providers’ qualifications and skills while getting them listed as approved providers by the insurance carriers. – PowerPoint PPT presentation

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Title: Understanding Provider Credentialing Process

Understanding Provider
Credentialing Process
Understanding Provider Credentialing Process
Basics of Provider Credentialing When any
healthcare organization hires a new physician,
nurse practitioner, or another healthcare service
provider, its essential to move them through the
medical credentialing process. Provider
credentialing allows you to verify providers
qualifications and skills while getting them
listed as approved providers by the insurance
carriers. Even though a provider has been
approved by insurance panels in the past, they
need to reapply each time while beginning to work
with a new employer or before adding into a new
practice. Medical credentialing is a
time-consuming process requiring a lot of correct
documentation. For understanding the provider
credentialing process in detail and to remove any
confusion, experts here at Legion Health Care
Solutions shared step by step guide on provider
credentialing. List of Insurance Carriers Make a
list of insurance carriers you want providers to
get credentialed with. This list will depend upon
your healthcare organizations location and
patient mix. You can review your current patient
data to list out the top ten insurance carriers.
If a significant portion of your medical billing
goes through a single insurance carrier, complete
their credentialing application first. Understand
every insurance carriers regulation and
credentialing guidelines. Some of them for
example, Aetna, allow a streamlined process for
providers who are already insured in another
state. That will result in quicker provider
Understanding Provider Credentialing Process
  • Complete Documentation
  • Provider credentialing starts with the timely
    submission of accurate documentation. Each
    insurance carrier requires different
    documentation and forms. Youll need to submit
    complete applications to each insurance carrier
    you plan to work with. Having complete and
    accurate documentation is key because even a
    single missing piece of information can delay
    approval by weeks or months. To ensure your
    applications are complete, make a list of all
    insurance providers you plan to file with. Then,
    list out any and all required documents, this
    list includes but is not limited to
  • Name
  • Social security number
  • Demographic information (ethnicity, gender,
    citizenship, languages spoken)
  • Education and residency information
  • Proof of licensure
  • Career history
  • Specialties and patient focus
  • Claim history
  • Proof of insurance
  • Information about your healthcare facility

Understanding Provider Credentialing Process
  • Check for Document Accuracy
  • Most of the time above mentioned information is
    available in your providers resume and
    application. You can cross-check that information
    for ensuring accuracy. Any errors in the
    submitted information can cause issues. If months
    and dates of employment are not easily and
    accurately verified by past employers, revising
    the application with the correct information can
    delay the approval process. Likewise, incorrect
    phone numbers for references or past employers
    can create delays or even rejections. To ensure
    accurate documentation you can follow a few
  • Conduct a background check
  • Verify educational history, licensing, board
    certification, and reputation through healthcare
    organizations such as the American Medical
    Association (AMA) the Educational Commission for
    Foreign Medical Graduates Certification (ECFMG),
    or the American Board of Medical Specialties
  • Review history of credentialing, privileges, and
    insurance claims
  • List any sanctions recorded with the Office of
    Inspector General (OIG)
  • Completing CAQH
  • The Council for Affordable Quality Healthcare
    (CAQH) is a web-based solution used to capture
    and share accurate, timely, electronic,
    self-reported provider data used for provider
    credentialing. Several major insurance carriers
    require partner facilities to apply for
    credentialing through the CAQH. When youre first
    getting credentialed with health plans, sometimes
    payers will use your CAQH application/profile and
    export it into their system. Once your practice
    has filed an application with an individual
    insurer, theyll provide a CAQH number and an
    invitation to apply.

Understanding Provider Credentialing Process
Youll be given the option to complete the CAQH
form on paper or online. After submitting the
initial application, be prepared to re-attest. To
maintain continuous insurance eligibility, youll
need to attest that a providers information is
correct four times each year. Wait for
Reply Once youve assembled and submitted your
application to payers, its time to wait for
their approval. This can be a lengthy process.
While most credentialing can be completed within
90 days, we suggest giving yourself 150 days. If
serious issues arise, credentialing can take even
longer. Follow Up Dont just wait five or six
months to hear from an insurance carrier.
Consistent follow-ups are key to timely approval.
Cultivate relationships with key personnel at the
insurance company. Check in via phone rather than
email to maximize the chance of a response.
Establishing rapport with leadership, executive
assistants, and other staff can help ensure that
applications move along in a timely manner. If
more information is required, compile and verify
all documents in a timely manner before
submitting them.
Understanding Provider Credentialing Process
Working with insurance carriers to get provider
credentialed is a tedious process and can consume
a significant portion of your healthcare
practices resources. After successful
credentialing, negotiating payment contracts is
another laborious process that requires your
continuous attention. After all, insurers
constantly change the terms of their payment
contracts. Legion Health Care Solutions can
assist you in provider enrollment and
credentialing. We are a leading medical billing
company that can assist you in revenue cycle
functions for your practice. You can free your
time for patient care by outsourcing your
credentialing requirements with us. Contact us at
727-475-1834 or email us at info_at_legionhealthcares
olutions.com to know more.
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