Medical Credentialing Services

Physician credentialing is the process of verifying a healthcare provider’s qualifications, credentials, and work history. This is done to ensure they meet the standards set by regulatory bodies, healthcare organizations, and insurance companies.

Although there might be deviations in the information requirements typically as per the insurance plans, the following is required:

• NPI Number
• CAQH profile (up-to-date)
• Practice information (Address, etc.)
• Medical License
• DEA license (If applicable)
• License to practice and primary source verification
• License history
• Insurance information
• Education: degrees and transcripts
• Board certification
• Detailed Work history
• References (Previous employers/practitioners)
• Malpractice claims history (Revocations, suspensions, etc)
• Malpractice Insurance
• Insurance login details (Medicaid, Medicare (Pecos), Availity etc.)

1. Verify NPI Registry for correct information and taxonomy. 
2. Check CAQH profile, ensure documentation is up-to-date and re-attested. 
3. Confirm with insurance if group/provider is contracted with requested payor. 
4. Fill out appropriate paperwork to get provider/group contracted. 
5. Review all paperwork carefully before submitting the application. 
6. Submit the application to the payor to complete the contracting process. 
7. Follow up every 2-3 weeks to ensure timely processing  
8. Informing providers on credentialing process approval 
9. Facilitate contract execution between the provider and Insurance enrollment plan.  
10. Confirm the effective date of in-network is the same or as close as possible to the initial request date.

The expected duration of the provider credentialing process can vary depending on various factors, such as the complexity of the application, the number of providers being credentialed, and the responsiveness of third-party organizations involved in the process. However, on average, the provider credentialing process can take anywhere from 60 to 90 to even 120 days. Outsourcing to a reliable  service provider can shorten the duration of the process efficiently and effectively.

Yes, having a service location is a crucial component of the credentialing. Insurance companies typically require providers to have a physical service location where they deliver healthcare services. This is where patients can contact the provider and show the provider’s presence in the community.

When you start the credentialing applications, you must give information about where you work, like the address and contact details. The insurance companies use this information to verify your eligibility and to ensure that you are accessible to patients seeking healthcare services. Having a well-defined service location is, therefore, an essential prerequisite for starting the credentialing journey.

It can vary based on your services, the people you serve, and location. When choosing insurance companies, consider their network size, plan options, reimbursement rates, and credentialing requirements.

It’s generally a good idea to start with the largest insurance companies in your area, as they tend to have the largest patient networks and offer the most coverage options. However, you should also consider other factors such as their plans, repayment terms, and approval process.

These additional aspects are important to take into account when making a decision. It is crucial to evaluate the plans offered by the company and determine if they align with your needs and goals. Additionally, understanding the repayment terms is essential to ensure you can comfortably meet the financial obligations. Lastly, assessing the ease of approval can save you time and effort in the application process.

You can hire a specialist company like Neolytix to handle provider enrollment (including Medicare enrollment) for you to help lessen at least one of the burdens of practice management.

Credentialing is about joining insurance panels to bill as an in-network provider for medical or insurance purposes. Primary Source Verification is the process of checking a provider’s credentials directly with the original source.

Healthcare organizations must verify the authenticity of degrees, work experience certifications, and licenses. This is necessary to prevent liability caused by providers using fraudulent methods. For instance, using fake degrees or falsifying resumes to get employment poses a significant threat to healthcare organizations. To prevent risks, healthcare organizations require doctors and providers to verify their credentials before hiring them.