Insurance Credentialing and Contracting: What it is and Why Its Important

Date:January 26, 2021 By:Admin

Insurance Credentialing and Contracting: What it is and Why Its Important

When talking about insurance credentialing and contracting, it indicates two sides of a coin that should be well understood by individual or group who are using it. The credentialing is part of the insurance company where it verifies education, training and work experience, ensuring that the individual meets the requirement to work in the service provider team. The main idea is to have team members aware of the procedure in detail and prevent patients from claiming anything in case the process goes wrong.
However, the insurance credentialing involves two parts, and they are credentialing preceded by contracting. Without correct knowledge on how to carry out the process, the companies may not deliver suitable service to clients. The following part talks about how contracting and credentialing intermingle with each one another.

Details of insurance credentialing

The credentials procedure should be undertaken as detailed under federal insurance rules. In this, the individual who has applied for the insurance need to justify that the professional records are suitable to be credentialed.
In the list of professional records, one should produce documents like diplomas, certificates, references, and other attestations. These are required to check the reputation and how the quality of service from the service provider. Similarly, an individual provider needs to furnish suitable documents when they want the same from a group. They have to submit the application which is properly filled, and it should be sent to credentialing authority for proper scrutiny before the credentials are offered to the applicant.

List of documents to be produced for credentialing and contracting

  • Give details of liability insurance policy
  • Be sure about practice location
  • It is important to have NPI number be it for an individual or an entity
  • Create a profile to obtain the credentialing and active the profile
  • Pick the right insurance company to participate in
  • For sole proprietors, it is better to have a federal tax ID
  • You need to have a full license for the state you will be operating from

What is the general procedure of credentialing?

  • First, you have to get in touch with a network service team to know about their insurance credentialing process and the steps to follow to apply. However, in most cases, the applications are available on the concerned website.
  • When filling up the application form, you have to mention the locations where you can opt for the service and enter other correct details and submit the required documents to complete the application
  • You have to check that the CAQH profile is well maintained with information such as practice location, license documents and board certificates
  • Try to check with the credentialing company that they have received the application, and it will help in easy follow-up until the credentialing has been completed and you are allotted a suitable date to contact the service provider and settle down for the required agreement
  • You can get in touch with the insurance company for any additional information
  • Make sure you have the copies of insurance credentialing applications and the related documents and also secure a final copy of the network copy from the insurance company for future reference
  • The credentialing procedure need to check the follow-up activities
  • You need to review the service provider for work details such as network provider, fees details, submission process, suitable filing limits, and other terms of agreement of the contract.
  • You have to maintain copies of application of credentialing and contracts and submit the same. Here, it is important to have the final copy when getting the work done quickly.

So, after the insurance credentialing and contracting process is complete, it is time to paying for the network service you are availing.

What is the importance of insurance credentialing?

When professionals are working with hospitals often think that they do not require insurance details. But the name of the professionals is already listed with reliable insurance companies. If you are involved with large practice or companies, individuals need to work as per the insurance company's contract. Therefore, proper insurance credentialing gives protection and leverage benefits. It is necessary to follow the steps mentioned above to have suitable insurance credentialing.

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