One of the first steps in medical billing is making sure the provider has been credentialed and enrolled by insurance payers and the Council for Affordable Quality Healthcare (CAQH®).

On average, the provider credentialing process can take between 60 to 120 days, so plan early. One mistake during the credentialing process can lead to a delay, which often results in having to start the process all over again. You don’t want that. 

If the provider isn’t properly credentialed or re-credentialed with the insurance company, the insurance payer will not reimburse the provider for services rendered. And to complicate things even further, you must constantly follow up with insurance payers to ensure the providers are enrolled in the network when enrollment is open.

Let’s explore the difference between provider credentialing and enrollment and review the critical steps you need to ensure an efficient credentialing process.

What is Provider Credentialing?

Provider credentialing, As defined by Joint Commission, is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization. During this process, which hospitals and health plans use, a provider’s education, work history, licensing, malpractice history, and more are reviewed, assuring your patients that they are receiving quality healthcare. Sometimes called medical provider credentialing, gathering and authenticating (verifying) a doctor’s credentials (professional background and educational history). Credentialing ensures that providers have the required licenses, certifications, and skills to care for patients properly.

Insurance plan credentialing is often referred to as “getting on insurance panels.” Getting a provider credentialed can be challenging and time-consuming—there is no one size fits all approach.

Also, most commercial insurance payers require re-credentialing every few years. Medicare requires re-validation every five years, DMEPOS suppliers re-validate every three years, and some states require Medicaid re-credentialing annually.

If you bill an insurance payer and the provider is not credentialed with the payer, this will lead to denied claims. Once the insurance payer denies the claim, most set time limits on re-submitting a claim. If a patient has secondary insurance, you can run into even more issues. The longer you wait, the more likely you won’t recover the maximum amount (or any) from the insurance payer.

What is Provider Enrollment? 

Provider enrollment is the process of enrolling a provider with commercial or government health insurance plans to which the provider can be reimbursed for the services rendered to patients. For example, once you have successfully enrolled with the insurance plan, the provider is considered “in-network.”

Pro Tip for Completing Medicare Provider Enrollment: Refer to the Medicare enrollment and certification website for instructions on how to access the PECOS (Provider Enrollment, Chain, and Ownership System) Medicare enrollment management system, becoming a Medicare provider or supplier, finding your taxonomy code, renewing your enrollment, ordering and certifying, enrolling as a DMEPOS supplier, and more.

What Are Critical Steps for Credentialing a Provider?

Why You Need a Reliable Provider Credentialing and Enrollment Process

The best revenue cycle management partner helps you simplify the provider credentialing and enrollment process by reviewing and gathering documentation to determine the provider’s participation in the health plan.

A reliable and efficient credentialing and enrollment service eliminates the headaches of submitting and tracking credentialing and enrollment applications based on the insurance plan requirements (and there are many).

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