Insurance Credentialing Services include verifying the qualifications and experience of healthcare providers for insurance network inclusion. It involves submitting an application and supporting documents like licenses, certifications, and malpractice insurance.

Necessary documents vary depending on the insurance plan and the type of healthcare provider. Here is a list of some basic documentation that is usually required. Documents for individuals:

• Practitioner License(s)
• Malpractice Insurance (Certificate of Insurance)
• DEA (federal) and state CDS certificates
• Board Certification(s)
• Current driver’s license
• CLIA Certificate
• Business License
• Letter of bank account verification
• IRS Form W-9

Insurance Credentialing is a vital step in ensuring that healthcare providers are paid correctly for their services and don’t suffer any financial losses. In order to obtain reimbursement for medical expenses, doctors and other healthcare professionals must provide insurance companies with proper verifications.

The turnaround time for insurance carriers varies, so there is no single answer to this question. Major Insurance normally takes between 90-120 days to complete the process, while smaller carriers and insurance plans may take longer.

When providers submit a participation request to a commercial carrier, they need to complete two processes. The first is credentialing, where the carrier verifies all provided credentials and presents them to their committee for approval. After providers are approved by the credentialing committee, they are directed to the contracting process, where their participation is approved, and they are provided their effective date. Company offering medical credentialing services also makes impacts on the duration.

If any insurance company denies your credentialing application, you have the right to appeal the decision. To file an appeal, you need to submit a letter to the insurance company that clearly and professionally explains why you believe you should be credentialed. In your letter, you should specifically address the reasons why your application was denied and include any additional documentation, such as letters of recommendation from colleagues or patients.

Once you have submitted your appeal letter, the insurance company will review it and provide a decision. If your appeal is successful, you will be credentialed with the insurance company. However, if your appeal is denied, you may file a complaint with your state’s insurance commissioner.

Medicare providers must revalidate every 5 years, while DMEPOS suppliers must revalidate every 3 years. Individual providers can use PECOS online or fill out the paper application. Groups or suppliers must complete the mandatory application. Establishing Electronic Funds Transfer is required for group records. Responding to the revalidation letter within 60 days is crucial. Failure to respond in time may result in the termination of billing privileges.

NPI 1 functions as your personal identification within the healthcare field, similar to a social security number. It remains linked to your professional journey and is exclusively assigned to you as the practitioner delivering services.

On the other hand, NPI 2 is an identifier for organizations, representing the location where services are provided. It can be associated with the employer’s company name for those working under an agency or with their business name for those in private practice.

We strongly recommend that businesses with a tax ID obtain an NPI 2. This is essential for establishing contracts with insurance panels at the organizational level, ensuring proper billing and payment for services. This becomes especially important as businesses and teams expand.

Additionally, certain insurance panels like Medicaid, Medicare, and BCBS require an NPI 2 for credentialing if the business has a tax ID.

Insurance panels often begin their process by referring to the information in your CAQH profile. When a healthcare provider submits an application on the panel’s website, the application undergoes a thorough review, and during this review, the panel frequently consults your CAQH profile to verify the information you’ve included in your application.

Medical credentialing services include a procedure to assess a provider’s suitability for inclusion in an insurance network, conducted before their membership. Recredentialing, which is performed periodically, typically every 1-3 years following the initial approval, aims to confirm the accuracy and currency of the provider’s details on the insurance panel.

Certainly, when you apply for credentialing through our organization, you have the freedom to choose the specific insurance networks you want to be affiliated with, and you can also specify the ones you’d like to exclude. Typically, most doctors working in outpatient settings opt to become credentialed with approximately 7-8 insurance providers. On the other hand, hospital-based physicians often choose a broader range, usually around 10-15 payors, to accommodate patients with various insurance plans who seek treatment within the hospital. In situations where physicians practice in the tri-state area, which denotes a location at the meeting point of three states, such as our physician-owned practice, it is customary to seek medical credentialing services with as many as 25 different insurance networks.