What is the Insurance Credentialing Process?

Receiving reimbursement is a necessary part of being able to practice medicine. Without that revenue, it would be impossible to keep a practice running and patient care would suffer. In today’s healthcare industry, most providers receive at least a portion of their reimbursement from insurance companies, and that means the need to go through the credentialing process. In this blog, we’ll explore what this process is, why it’s important, and what the steps are so that you’re prepared to undertake this important task. Let’s get started.

What is insurance credentialing and why is it important?

Insurance credentialing refers to the collection and verification of a clinician’s qualifications including training, academic background, licensure, and certification and/or registration. Through credentialing, a provider becomes affiliated with an insurance company in order to be able to receive third-party reimbursement for care services rendered.

Insurance credentialing is important because it enables a provider to receive reimbursement from health insurance companies, which is one of the main ways clinicians are paid for their services. Unless a provider intends to work entirely in a direct primary care capacity, they will need to undergo the insurance credentialing process in order to get paid.

What are the steps in the insurance credentialing process?

When completing insurance credentialing, it’s important to understand exactly what is necessary to be successful. This is a complex process that can cause significant issues if not completed properly.

The first step is to determine what documents you need. Each insurance company requires different forms and documentation, and even one missing piece of information can delay your approval by up to months. Some of the most commonly required information includes:

• Name
• Social security number
• Ethnicity, gender, citizenship, spoken languages and other demographic information
• Education and residency
• Proof of license
• History of career
• Specialties
• History of claims
• Proof of insurance
• Information about the facility of practice

Next, you’ll want to decide which insurance companies are most vital to apply to and start there. Credentialing is a time-consuming process, so it’s best to determine where most of the provider’s claims will be billed and start with those insurance companies. Often, once a provider is credentialed with one insurance company the process becomes easier for other insurers.

At this point you’ll need to make sure that all of the information you have is accurate. We can’t stress this enough, if you submit incorrect information, there will be issues. Double check absolutely everything you have to be completely certain it’s correct.

Once you have all of your information and you’re positive that it’s correct, you’ll complete the CAQH. This is the Council for Affordable Quality Healthcare, and many major insurers require facilities to apply for credentialing through this body.

After completing the CAQH, you’ll wait for verification. This can be done within 90 days, but it’s best to allow upwards of 150 days for the verification process. Note that if any issues come up, the process will take even longer.

However, while you’re waiting, follow up. Don’t allow up to six months to pass without hearing from any insurers. Consistently following up on applications is integral to receiving approval in a timely manner.

Finally, there is the recertification process. It’s important to note that credentialing is an ongoing process, with most providers needing to be re-credentialed every three years. Additionally, it’s necessary to promptly correct any information errors you might notice over time.

Once you’ve completed the credentialing process, you will step into the contracting process which takes place after a clinician has been approved by a credentialing committee. During this step the clinician is offered a contract for participation in a health insurance network, and any negotiation over reimbursement rates will take place.

Finally, it’s important to note that the process to enroll as a provider in Medicare, Medicaid, or any other government health program is different and incredibly detailed. Be sure to collect thorough information on what is required for those processes before beginning as well.

Insurance credentialing is a complex process, but one that is necessary in our current healthcare industry. With good attention to detail and a great deal of care, the credentialing process is one that can be handled relatively seamlessly, allowing the provider to focus on patient care and billing to be handled smoothly.