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.
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Basics of Provider Credentialing
The provider is then informed of their decision.
Providers are generally credentialed for a
three-year period. However, the credentialing
department may 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.
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Basics of Provider Credentialing
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. 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 program.
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Basics of Provider Credentialing

• 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
• 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

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Basics of Provider Credentialing

• medical record audit scores member concerns
  peer review and continuity of care.
• 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
• 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.

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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. FAQs  1. What is provider
credentialing? Provider credentialing is the
process of verifying a healthcare providers
qualifications, experience, and licensing to
ensure they meet the standards of healthcare
organizations and insurance companies. 2. Why is
provider credentialing important? Credentialing
ensures providers meet regulatory and payer
requirements, enabling them to treat patients and
receive reimbursements from insurance
companies. 3. How long does the credentialing
process take? The process typically takes 60-90
days but can vary depending on the payer and the
completeness of the provider's submitted
documentation.
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Basics of Provider Credentialing
4. What documents are needed for
credentialing? Common documents include medical
licenses, malpractice insurance, educational
certificates, work history, and references. 5.
Who handles provider credentialing? Credentialing
can be managed by the provider, their office
staff, or outsourced to specialized credentialing
services like medical billing companies.