Process of Credentialing a provider with an Insurance Company

Provider credentialing can be an extremely frustrating process, especially for professionals who haven’t done it before. So if you also want to become an in-network provider, then here’s an overview of what goes into the provider enrolment procedure related to commercial payers:

  • The first thing you need to do is to determine the insurance companies you want to participate with. It will take at least 2-6 hours on each application, including the preparation and follow-up. Many healthcare providers choose to outsource this task to a third party, considering the complexities.
  • At times, physicians starting a new practice feel that just because they worked for an organisation previously and were in-network, they don’t need to do anything for their new practice. This however isn’t true. In many cases, such providers were participating under the previous organisations group contract which isn’t going to get transferred to the new private practice. In this situation, they need to contact each plan and determine their contract status and get the necessary instructions on setting up the new practice. But if they were participating under an individual contract, they can transfer the contract to a new practice. So the entire process will vary in different plans.
  • If you are credentialing with commercial payers, including HMOs and PPOs, then you need to start by obtaining your CAQH ID or by updating your profile to ensure that it has all the correct information on the file.
  • The next step will be to join the network on the insurance company’s website. Contact the payer to follow-up with the request you have made. Then comes the step of panel determination and finding if the panel is open or not. As soon as the initial information has been submitted, the provider needs to get a reference or ticket number from the payer.
  • Next step involves following-up. The provider will have to call the payer frequently to ensure that everything is processing correctly. Another step will involve moving to contracting once the credentialing or primary verification is complete.

The payer will then draft the agreement around the 90 day mark and it will move to the contracting department. Once the contract gets approved at the payer level, it will be emailed to the provider for reviewing. The payer participation will then be verified and once the billing system gets updated with the payer information, claims can be submitted.

Leave a Reply

Your email address will not be published. Required fields are marked *