Basics of Provider Credentialing - PowerPoint PPT Presentation

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Basics of Provider Credentialing


Provider credentialing requirements for all commercial payers varies (even state-wise) so you are requested to consider this article just a reference to understand the basics of provider credentialing. – PowerPoint PPT presentation

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Title: Basics of Provider Credentialing

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Basics of Provider Credentialing
The provider credentialing process for every
commercial insurance carrier varies to a certain
extent. In this article, we discussed standard
provider credentialing requirements for all
commercial payers. You are requested to consider
these credentialing requirements just as a
reference purpose. So lets understand the basics
of provider credentialing. The basics of
provider credentialing Initial Application The
Credentialing department reviews your
applications within 45-60 days of receiving a
fully completed application. If additional
information is needed, the payers will respond
within 2-3 weeks. Applicants are notified within
that period if credentialing has been approved or
if additional time is needed. The payers contact
applicants to obtain any missing documentation.
Once the initial application and all applicable
verifications are completed, the credentialing
department, considers all information gathered on
the provider and evaluates the provider based on
payer-specific credentialing criteria. The
credentialing department decides to approve or
deny the providers application. The provider is
then informed of their decision. Providers are
generally credentialed for a three-year period.
However, the credentialing department may
Basics of Provider Credentialing
recommend credentialing for a shorter period
based on the results of its review. If so, the
provider is advised of the decision and the
reason for the shorter approval period. CAQH
ProView Insurance carrier validates the accuracy
of a providers service location data during both
credentialing and re-credentialing by reviewing
the providers data in CAQH ProView and
performing telephone outreach. Payers require all
applicants for all networks to complete the
Council for Affordable Quality Healthcare (CAQH)
ProView credentialing application form. If you
do not have a CAQH number, register with CAQH
ProView. Getting Credentialed The credentialing
department performs the initial approval and
credentialing of providers and facilities for
participation with payer networks. The
credentialing department will review and verify
the completeness of every providers application.
This includes primary source verification of the
providers licensure and accreditation. The
Centers for Medicare Medicaid Services (CMS)
requires primary source verification of education
and training records and board certification. The
credentialing department reassesses providers and
organizational providers every three years (at
minimum) to assure all credentialed providers and
organizations remain qualified and continue to
meet payers criteria for participation.
Basics of Provider Credentialing
  • When contracting with New York State
    (NYS)-designated providers, payers will not
    separately credential individual staff members in
    their capacity as employees of these programs.
    Payers will still conduct program integrity
    reviews to ensure provider staff is not disbarred
    from Medicaid or in any other way excluded from
    Medicaid reimbursement. Payers will still collect
    and accept program integrity-related information
    from these providers, as required in the Medicaid
    Managed Care Model Contract. This means they
    require such providers to not employ or contract
    with any employee, subcontractor, or agent who
    has been debarred or suspended by the federal or
    state government or otherwise excluded from
    participation in the Medicare or Medicaid
  • Qualification Requirements
  • Every commercial insurance carrier has unique
    qualification requirements. For reference we
    shared some standard qualification requirements 
  • A valid, unencumbered license to practice
  • Board Certification in practice specialty within
    5 years of completion of training
  • Current malpractice insurance coverage within
    acceptable limits
  • Acceptable malpractice history

Basics of Provider Credentialing
  • Regulatory program participation status
  • Provider Re-credentialing
  • On average commercial insurance carrier requires
    all providers to undergo re-credentialing every
    three years. Providers must maintain the same
    minimum qualification requirements as applicable
    for the initial credentialing. The
    re-credentialing process evaluates each
    practitioner on the evaluation parameters like
    access and availability quality of care primary
    and secondary prevention disease management
    member satisfaction medical record audit scores
    member concerns peer review and continuity of
  • Generally, six (6) months prior to the expiration
    of credentials, providers receive a letter from
    the credentialing department for
    re-credentialing. In this communication,
    providers are requested to update their CAQH
    ProView application with some of the documents
  • Malpractice claims history (if applicable)
  • Updated copies of their curriculum vitae, state
    license, and Drug Enforcement Administration
    (DEA) certification

Basics of Provider Credentialing
  • Proof of malpractice insurance coverage
  • Providers with a complete application on file
    with CAQH ProView can communicate with the payer
    to retrieve all documentation from this source.
    To ensure credentialing status with payers, it is
    important to update all re-credentialing
    materials as soon as possible. Failure to respond
    in a timely manner could result in termination
    from providers networks.
  • Medical Billers and Coders (MBC) is a leading
    medical billing company providing complete
    billing and coding services. Provider
    credentialing requirements for all commercial
    payers vary (even state-wise) so you are
    requested to consider this article just a
    reference to understand the basics of provider
    credentialing. If you need professional guidance
    for credentialing and re-credentialing for
    government and commercial payers (for all
    states), email us at info_at_medicalbillersandcoders
    .com or call us at 888-357-3226.
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