INSURANCE CREDENTIALING SERVICES

WHAT IS INSURANCE CREDENTIALIGN?

Insurance Credentialing is the process the healthcare facility or managed care organization/health plan uses to collect and verify the “credentials” of the applicant. This includes verification of many elements including licensure, education, training, experience, competency, and judgment.

Physicians and other healthcare providers who wish to provide care in a hospital, ambulatory care facility, or other healthcare facility must undergo an application process which includes verification of credentials. Additionally, providers that want to bill an insurance company and receive reimbursement for services as an in-network provider must undergo a process of credentialing. Healthcare facilities and health plans will verify relevant education including medical school, residency/fellowship training, board certification, licensure, professional liability insurance and claims history, and will query the National Practitioner Data Bank (NPDB). The NPDB is an electronic repository containing information on medical malpractice payments and certain adverse actions related to healthcare practitioners, entities, providers, and suppliers.

Insurance Credentialing Services

PROVIDER ENROLLMENT VS PROVIDER CREDENTIALING

Provider credentialing is different from provider enrollment. Provider enrollment is the process of enrolling a provider with insurance payers. The provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty.  After the application is submitted and credentials are verified, the approval process will involve review and approval by the network’s medical director or credentialing committee.

Process of Credentialing:

Our Step-by-Step Physician Credentialing Process Strategy and Information Gathering

Collect documents and provider information:

  1. Gather personal and organizational information, including CV, license information, Tax ID, NPIs’ practice address, pay-to address, etc.
  2. Help providers in the process of selecting insurance carriers they would want to be credentialed with.

Application Submission
Start filling out and submitting applications online or on paper for insurance companies to review and start the process.

Follow-Up 

  1. Rigorous action is taken to make sure that the application is not pending for corrections or missing document(s).
  2. Continuous follow up with insurance carriers to get the updates on credentialing process.
  3. Once the application has been made through the initial process, we will ensure that it transitions smoothly into the contracting phase.

Contract Negotiations and Effective Dates

    1. When enrollment is approved, the insurance carriers will email/mail the contract for provider signature. If needed, payers’ agreements are reviewed and negotiated.
    2. After the provider signs, these agreements are returned to the payers for loading into their system to ensure that provider is in network.
    3. We ensure that the effective dates to start seeing patients, as well as provider IDs for the applicable payers, are received.
    4. Finally, we provide this information to your billing/administrative department or your billing company so that you can start seeing patients and have an uninterrupted cash flow.

CAQH Registration

CAQH has an online database for storing provider information and sharing it with insurance companies. Many insurance companies require providers to use the CAQH database so that they can obtain credentials directly during enrollment.

Steps:

  1. Create a secure Username and Password for providers.
  2. Complete the application and submit the required documentation.
  3. Fax/upload signed attestation to certify the accuracy of the application.
  4. Grant insurance companies access to the online application.

MEDICARE ENROLLMENT

Medicare enrollment can cost you thousands of dollars in lost revenue if done incorrectly. We specialize in all aspects of medical enrollment and will work to enroll you quickly and correctly with your local Medicare administrator. We can get you credentialed faster through PECOS (Prover Enrollment, Chain and Ownership System) because we already have an active account with PECOS.

Steps:

  1. Start credentialing through PECOS.
  2. Submit enrollment application for individual physician and non-physician practitioners.
  3. Submit enrollment application for Clinics/Group Practices and Certain other Suppliers.
  4. Submit enrollment application for Reassignment of Medicare Benefits (individual physicians and non-physicians).
  5. Upload signed attestation and documents.
  6. Follow up in a timely manner to ensure application is complete and all the documents are uploaded.
  7. PTAN (Provider Transaction Access Number) is issued by MAC (Medicare Administrative Contractor) upon approval of enrollment.
  8. Submit EFT application for the transfer of electronic funds to the provider’s account.

MEDICAID ENROLLMENT

Medicare and Medicaid are separate programs. Submitting an application to Medicare does not mean you have also submitted an application to Medicaid. Enrollment approval in Medicare does not guarantee enrollment approval in Medicaid. Therefore, a separate enrollment with Medicaid is required.

Steps:

  1. Create a secure account and obtain User ID and Password.
  2. Submit application online for individual practices, group practices, and organizations.
  3. Upload required documentation.
  4. Attest to certify the accuracy of the application.
  5. Submit EFT application.
  6. We will not sign off until the provider receives a decision from the insurance carriers.

PPO/HMO ENROLLMENT

PPO (Preferred Provider Organization) and HMO (Health Maintenance Organization) are two different programs. Both plans use a network of physicians, hospitals, and other healthcare professionals. Credentialing with PPO and HMO carriers is done separately as per the provider’s request to join the network.

Steps:

  1. An application is obtained from the insurance carriers.
  2. A complete application with documentation is submitted.
  3. The provider receives a contract and guidelines for reimbursement from the insurance carriers for signature.
  4. Upon approval of network status, an executed contract is received from insurance carrier.
  5. Contracted rate of reimbursement can be negotiated with insurance carriers on behalf of the provider.
  6. We will not sign off until the provider receives a decision from the insurance carriers.