Title: Basics of Provider Credentialing
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2Basics 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
3Basics 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.
4Basics 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
program. - 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
5Basics 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
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
6Basics 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.