Credentialing & Provider Enrollment
Credentialing is a process used to evaluate the qualifications and practice history of a doctor. This process includes a review of a doctor’s completed education, training, residency and licenses. It also includes any certifications issued by a board in the doctor’s area of specialty. The credentialing process is used by insurance companies to allow the provider to participate in their network. The credentialing process is used by insurance companies to allow the provider to participate in their network.
Enrollment refers to the process of requesting participation in a health insurance network as a provider. The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract. Enrollment is also the validation of a provider in a Insurance plan and the approval to bill the insurance for services rendered.
Step by Step Process:
Step 1 – Obtain the complete information from the providers office, make sure all the information are correct and up to date. Most importantly need to get the PECOS and CAQH login information from the provider (If they have).
Step 2 – Confirm with the provider on the insurances which needs to be credentialed, Provider can opt for insurances based on their state/specialty.
Step 3 – Based on the insurance list, Call the specific insurances – reach the credentialing/enrollment/provider relations department and cross verify whether the provider is already credentialed/participating under any other group/further steps to get the provider credentialed with the insurance company.
Step 4 – Complete and submit applications with correct information and attach required documents.
Step 5 – In case of commercial insurances apart from online applications few of them request submitting a letter of interest/ intent along with W9 form.
Step 6 – After completion and submission of applications we need to start following up with insurances every 10 days for the receipt and processing status.
Step 7 – Processing time for some insurance listed below
Medicare – 45 to 90 days (At times 120 days)
Medicaid – 15 days to 90 days (At times 120 days)
Commercial Insurances – In case of commercial insurance they have two steps, Initial credentialing takes place between 30-60 days and then followed by contracting which usually takes place between another 30-60 days.