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What is insurance credentialing

what is insurance credentialing

Medical Credentialing Services

Credentialing is the process by which the experience and qualifications of physicians and medical practices are evaluated and validated. Typically an objective evaluation that takes into account a practice’s licensing, education and training history, credentialing is critical for providers that wish to become part of a payor network. Providers must obtain credentialing to become part of a payor network. Without credentialing in place, a practice will be unable to provide care for patients covered by a particular insurance company.

Without complete and proper credentialing, an insurance company may choose to make only a partial claim, requiring the patient to pay the balance. By fulfilling a critical payor network requirement, credentialing ensures better revenue realization for the provider.

It is hard enough to practice medicine. Dealing with insurance companies adds another level of complexity to health care today. It is important that you have a partner in credentialing that has the experience and proven results to get you started on the right foot!


Payor Enrollment / Solo or Group Practice Start-Up Services

New practice start-up services can include all or parts of the following

  • NPI Registration - Type 2: Health care providers who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.
  • CAQH Credentialing
  • Fast & Accurate Completion of all Applications for Commercial Insurance Companies
  • Medicare Enrollment for Group Practices and Individuals
  • Medicare EFT Enrollment for Individuals and Groups
  • ERA/EFT Set Up Assistance for Commercial Carriers
  • Tracking & Confirmation of all insurance contracts, PAR ID's & effective dates
  • Weekly or Bi-Weekly Status Reports
  • Prices based on the number of providers & plans
  • To start this process, we will require a list of details & documents from you.

Timeline For Above Services

The amount of time required to complete the credentialing process will vary based on practice location & the plan itself, but the average time is approximately 90-120 days. It is important to plan ahead and to start this process as soon as possible. Medicare will only backdate effective dates thirty (30) days from the date they receive an enrollment application & the effective dates for the commercial plans can vary.


Payor Enrollment / Adding a New Physician(s) to your existing practice

If you have hired a new provider(s) & need to get him/her credentialed & linked to your existing contracts, our services can include all or parts of the following:


Maintenance & Recredentialing

The maintenance and recredentialing service is a great fit for any practice that doesn't have the staff or expertise to handle the credentialing aspect of the practice. By selecting to

use our Recredentialing services, we will ensure that all of your providers are properly recredentialed and maintained to prevent claim denials and ensure timely payments from insurers. Contact us for more information on this service to start saving your practice money and cut down on administrative costs.


CAQH Credentialing

If you are looking for assistance in obtaining a CAQH profile, let our industry experts set up your CAQH profile. We will obtain your unique CAQH ID and have your application completed in less than two weeks. The first step is to obtain a CAQH ID, which is issued by participating insurance companies. We can obtain a CAQH ID in less than 1 week in most cases because of the volume of applications that we process.



Enrolling providers with Medicare and Medicaid and commercial payors requires individual forms and unique checklists of documentation, not to mention accuracy, time, patience & follow-up. This includes keeping your providers enrolled in the managed care plans and ensuring their information is accurate with each payor.

Do not forget about re-credentialing providers every 2-3 years, reviewing fee schedules, reviewing network directories, managing CAQH profiles, terminating providers from your contracts, demographic changes, etc. If your practice and providers are not credentialed and/or contracted correctly with the networks, it can result in lower reimbursement and/or denied claims.

Additionally, most practices investigate unpaid/denied claims on a case-by-case basis. Although an important procedure, you should also review the causes of denials on an aggregate basis. If most claim denials result from inactive provider numbers, that issue needs to be resolved before additional claims are submitted; otherwise, the denials will continue. In addition, we’ve encountered practices not being paid by the insurer or health plan because they reversed the routing and account numbers for the Electronic Funds Transactions. Without looking at the non-payment issue at the aggregate level, this problem would have just continued with office staff trying to resolve each unpaid and/or denied claim one at a time.

It’s also critical that you maintain copies of your payor contracts from each insurer and health plan. These contracts include fee schedules for the CPT codes, criteria for termination, and tons of other important information that your practice should be aware of. However, most practices do not even know where their contracts are nor do they know their fee schedules. Most have never analyzed their fee schedules to determine if they are losing money. It is important to review contracts and fee schedules on an annual basis due to the ever changing reimbursement rates. The networks will not inform you that you are on old fee schedules and that you are leaving thousands of dollars on the table.


Category: Insurance

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