Provider Credentialing Process Flow Chart

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Provider Credentialing Process Flow
Chart
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Provider Credentialing Process Flow Chart
Provider credentialing is a critical process in
the healthcare industry, which involves the
verification of a healthcare providers
credentials, qualifications, and experience to
ensure they meet certain standards set by the
insurance companies. The provider credentialing
process flow chart is a critical tool that can
help healthcare providers by streamlining the
credentialing process and ensuring that they meet
the necessary qualifications to provide quality
healthcare services to patients. By following the
flow chart, healthcare providers can understand
the steps required to complete the credentialing
process and prepare for the information and
documentation needed to complete their
application. Step 1 Provider Application The
healthcare provider interested in joining the
network completes an application and submits it
to the healthcare organization or insurance
company. The provider completes an online
application and attaches all requested supporting
documents containing data on their work history,
education, references, and more. The application
also includes instructions for the provider on
what to list and how far back to go when
detailing their history. The credentialing or
enrollment professionals role is to follow up
until all necessary data and documentation is
received, with provider data management software
used to keep both parties on track.
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Provider Credentialing Process Flow Chart
Step 2 Primary Source Verification (PSV) The
healthcare organization or insurance company
verifies the accuracy of the information provided
by the provider through Primary source
verification (PSV). Primary source verification
is the act of going directly to the issuer of the
data or certificate to verify credentials, either
before or after a completed application is
received, depending on the healthcare
organizations policy and protocol. Another
organization may act as an agent for the primary
source in providing information for PSV. PSV is
critical to the credentialing process, as it
helps to identify impostors or individuals who
exaggerate or fabricate professional
qualifications to gain access to patients,
creating significant risk. Credentialing and
enrollment professionals must be vigilant in
conducting PSV, as they often operate with
limited staff resources and under strict time
constraints to on board providers quickly, so
hospitals can serve patients and receive
payment. Step 3 Credentialing Committee
Review The credentialing committee carefully
reviews the providers application and
accompanying documents to ensure that they meet
the insurance companys standards and
requirements for credentialing. The committee may
conduct additional background checks and review
any red flags identified during the primary
source verification process before making a
recommendation to either approve or deny the
providers application. This step ensures that
only qualified and competent providers are
granted privileges to practice within the
healthcare organization.
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Provider Credentialing Process Flow Chart
Step 4 Approval/Denial of Credentialing The
credentialing committee reviews the providers
application and accompanying documents and makes
a recommendation based on the providers
qualifications, compliance with industry
standards and regulations, and other relevant
information. Then the insurance companys
internal committee may make the final decision or
may submit their recommendation to an external
accrediting organization for review. The
accrediting organization may review the
recommendation and make a final decision on
behalf of the insurance company. If the
providers application is approved, they become
part of the insurance companys network of
providers and are eligible to receive
reimbursement for services provided to patients
with insurance coverage. If the application is
denied, the provider may have the opportunity to
appeal the decision through the insurance
companys appeals process. Step 5 Contracting
and Enrollment If the provider is approved for
credentialing, the insurance company will
typically enter into a contract with the provider
and enroll them in their network. The contracting
process involves negotiating the terms and
conditions of the agreement between the provider
and the insurance company. This may include
negotiating reimbursement rates, contractual
obligations, and other terms of the agreement.
The contract serves as a formal agreement between
the provider and the insurance company, outlining
the rights and obligations of both parties.
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Provider Credentialing Process Flow Chart
Enrollment is the process of adding the provider
to the insurance companys network of providers.
This involves updating the providers information
in the insurance companys provider directory and
other databases, so that patients can easily find
and access the providers services. During the
enrollment process, the insurance company may
also verify the providers credentials and ensure
that they are in compliance with regulatory and
contractual requirements. This includes verifying
that the provider has active licensure and
certifications, has not been excluded from
federal or state healthcare programs, and is not
subject to any sanctions or disciplinary
actions. Once the contracting and enrollment
processes are complete, the provider is
officially part of the insurance companys
network and can begin providing services to
patients with insurance coverage. The provider is
responsible for complying with the terms of the
contract, including billing and coding
requirements, quality assurance standards, and
other contractual obligations. Step 6
Re-Credentialing Re-credentialing is the process
of periodically reviewing and verifying a
providers credentials to ensure that they
continue to meet the insurance companys
requirements for participation in their network.
Providers are typically required to go through
the credentialing process on a regular basis,
usually every two to three years, to ensure that
they continue to meet the organizations or
companys credentialing standards.
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Provider Credentialing Process Flow Chart
During the re-credentialing process, the
insurance company may review the providers
professional qualifications, work history,
malpractice history, and other relevant
information. The re-credentialing process
typically involves sending the provider a
re-credentialing application, which they must
complete and submit along with any required
supporting documentation. The insurance company
may also conduct a site visit or interview with
the provider to verify their credentials and
ensure that they are in compliance with
contractual and regulatory requirements. Once
the re-credentialing process is complete, the
insurance company will either approve the
provider for continued participation in their
network or deny their application. If the
provider is denied, they may have the opportunity
to appeal the decision or take steps to address
any deficiencies that were identified during the
re-credentialing process. The provider
credentialing process flow chart provides
transparency in the process, ensuring that
providers are informed of the status of their
application and any issues that need to be
addressed. Ultimately, the flow chart helps
providers navigate the credentialing process with
greater ease and efficiency, allowing them to
focus on providing high-quality care to their
patients.
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Provider Credentialing Process Flow Chart
About Legion Healthcare Solutions Legion
Healthcare Solutions is a leading provider
credentialing service provider that specializes
in assisting providers with complete steps of
credentialing process. With years of experience
in the industry, Legion Healthcare Solutions has
a team of knowledgeable and experienced
credentialing professionals who understand the
intricacies of the credentialing process and work
tirelessly to ensure that all providers meet the
necessary standards for participation in a
healthcare network. As a trusted provider
credentialing service provider, Legion Healthcare
Solutions has built a reputation for excellence,
reliability, and exceptional customer service,
making them the go-to choice for healthcare
providers looking to streamline their
credentialing process. To know more about our
credentialing and enrollment services, contact us
at 727-475-1834 or email us at info_at_legionhealthca
resolutions.com
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