Provider Credentialing - Overview and Checklist

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Provider Credentialing - Overview and Checklist

• Provider credentialing is important as it opens
  up new revenue opportunities like a credential
  provider gets an increased number of patients
  through referrals from payers. Moreover,
  credentialing ensures the patient that they are
  getting treatment from a credible provider.
• What is Provider Credentialing?
• Provider credentialing is a process in which a
  provider's qualifications and competency-based on
  demonstrated competence are formally assessed by
  a health insurance carrier. This process is
  time-consuming and takes up to three months to
  complete. The need for extensive background
  information submission is the main reason behind
  the lengthy process. Depending on the
  circumstances, the clinic or organization for
  which the provider is working may also need to go
  through credentialing.
• Provider needs to satisfy the following criteria
  for credentialing
• Has an unrestricted license
• Any disciplinary actions or sanctions by
  insurers, hospitals, licensing boards, or
  professional organizations
• Presence of any criminal history
• Is the Provider certified by the medical board?
• General health status

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Provider Credentialing - Overview and Checklist
If a physician meets standards for delivering
clinical care then the credential process is
validated and usually takes 60 -120 days for a
payer to get credentialed. While the process of
credentialing is in process, some providers have
doubts that "can they work during the
Credentialing Process? The answer to the above
question is "No. A healthcare provider needs to
wait for completion and approval of the
credentialing process approved before they can
begin to work. This assures that every patient
receives care from properly educated and
experienced professionals at all times to treat
their healthcare concerns. It is a legal risk
for any facility which allows non-credentialed
individuals to work, even if they are in the
process of getting their credentials. Following
are some checklist for accurate application of
hurdle-free credentialing process
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Provider Credentialing - Overview and Checklist

• Provider start date in practice
• Copy of state license
• Copy of DEA
• Provider DOB and SSN
• NPI Number
• Updated CV- work history
• NPPES logons
• CAQH logons
• Malpractice incidence details
• Copy of Degree/Diploma certificates
• Copy of Driving License
• Group Name
• GNPI Tax id
• Practice and billing address along with Phone and
  Fax
• Signed W-9 Form

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Provider Credentialing - Overview and Checklist

• Role of CAQH in Provider credentialing
• The Center for Affordable Quality Healthcare,
  Inc. (CAQH) is one of the most frequently-used
  Web services for credentialing. CAQH offers an
  online database called the Universal Provider
  Data source (UPD) that collects all of the
  information required for credentialing and then
  makes it available to third-party payers.
• There are three steps to getting set up in CAQH
• Obtain your CAQH ID (within 2-3 business days)
• Set up your secure username and password
• Complete the online application and send in the
  required documentation
• Send your attestation for signature, which
  certifies the application
• Grant insurance companies access to your online
  application
• Not having a completed, up-to-date CAQH
  application will delay your enrollment with the
  insurance companies. Furthermore, this will
  prevent you from getting reimbursed for your
  services.

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Provider Credentialing - Overview and Checklist
Generally, the process can take anywhere from
several days to several weeks. It can vary
depending on what field you seek credentials in,
what CVO you are using, and whether you have
provided all supporting documents and filled out
the application correctly. For this reason, it
is normally best to begin the application
process 90 days before your start date at a new
facility. Ninety days allows for some margin in
case verification entities do not promptly
respond to requests or if the CVO must
investigate discrepancies for clarification. If
you are looking for guidance and support for
provider credentialing then you can outsource
credentialing to a reliable and professional
physician credentialing service provider like us.