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?

  • Make a list and collect all information you need for provider credentialing applications: professional licenses, work history (curriculum vitae or resume), certifications, malpractice insurance certificate, references, practice ownership details, W-9, background checks, bank statements, more.
  • Get the provider’s National Provider Identifier (NPI), Federal Tax ID, and Practice EIN (this must match what is listed on the provider’s W-9 form).
  • Register the provider with CAQH and obtain their CAQH ID. Make sure CAQH has a valid W-9 and malpractice certificate for the provider. Confirm that the dates of employment and education are in the “month/year” format. If you don’t post valid dates, CAQH will reject the application. CAQH will notify the provider quarterly via an email to “re-attest” that the information in the profile is current—always reply promptly.
  • Confirm if you need the original handwritten signature of the provider to process the credentialing request.
  • Complete and submit a series of applications with each insurance payer.
  • Once you complete the initial credentialing review, always get a “reference number” from the insurance payer and document this in your credentialing tracking records.
  • Follow-up with insurance payers on the provider’s credentialing application status—they are notorious for not calling back if something is missing from the application. Document all follow-up calls or online communications throughout the credentialing process.
  • Ensure your billing system is updated with payer information: Electronic Data Interchange (EDI) enrollment. 
  • Review the fee schedule before you sign a credentialing contract with an insurance payer. You may need to request a fee schedule and provide the payer with your top 20 billing codes.
  • Keep copies of all credentialing applications and contracts you submit, as well as credentialing and enrollment letters you receive from the insurance payer.

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).