Insurance Credentialing
The requesting inclusion in health insurance networks’ provider panels refers to the insurance credentialing process, sometimes known as provider enrollment. Let’s discuss the process of insurance credentialing services.
Insurance Credentialing Process
The insurance credentialing services process has two parts for networks that provide commercial insurance: 1) credentialing and 2) contracting.
1. Credentialing
The first step is for the provider to use the health plan’s application process for credentialing to submit a participation request. Application procedures for insurance credentials can include filling out a special application, using CAQH, or accepting a nationally standardized application. When a provider applies for credentialing, the health plan thoroughly verifies his or her qualifications to make sure the provider satisfies the requirements for credentialing. The Credentialing Committee receives their credentialing application for approval when all credentials verification (Primary Source Verification) completes. Networks should finish this process in up to 90 days.
2. Contracting
The second stage of the procedure, contracting, starts after the Credentialing Committee gives its approval. The provider receives a contract for participation after granting credentialing approval during the Contracting stage of enrolment. The contracting procedure is handled by separate people from the credentialing phase in the majority of commercial insurance networks. You evaluate the contract’s text, reimbursement rates, and any other specifics and obligations of participation during the contracting phase before signing your agreement. If the standard reimbursement rates fall short of your expectations, this is when rate negotiations start. You are provided with an effective date and provider number so that you can start invoicing the plan and getting “In-Network” reimbursement for your claims after your agreement has been signed and returned to the network. Expect this procedure to take networks 30 to 45 days (after credentialing is complete).
Medicare, Medicaid, Tricare, and other government health programs all have slightly different provider enrollment processes. Standard forms for these programs must be completed and forwarded to the correct intermediary who manages all administrative tasks for the program in your area. Medicare evaluates your application based on rigorous enrollment requirements. On the CMS website, you can access a wealth of enrollment-related information on Medicare. When applying for Medicare, keep the following things in mind:
Points To Remember
- You must have a main office where you conduct business (or in final preparation)
- To set up EFT payment for your Medicare reimbursement, you’ll need banking information.
- Each person who owns a share in your business must supply their contact information.
- The supporting documentation depends on the type of enrolling provider.
- Providers born outside of the United States must produce proof of citizenship.
- Providers’ education outside of the United States must be certified by the ECFMG.
- Properly sign your application paperwork at each signature point.
