Credentialing FAQ

For many healthcare practices, credentialing can be both confusing and overwhelming.

At Credentialing, we provide a full-service credentialing solution. Let us handle the complicated processes and the repeated follow up calls with insurance companies for you.

Listed below are answers to some of the most frequently asked questions about the credentialing process. Take some time and review the information below or simply call us at (855) 664-5154 with your questions, and we’ll be happy to help!

Q: Why would someone want or need credentialing?

Being credentialed with insurance panels means that you are able to see patients who have specific insurance plans and bill those insurance companies directly for the services you render. This can greatly increase the number of patients who can access your services.

Q: What is the process of getting credentialed with insurance companies?

Q: Do I get to choose the panels I want to be on?

Yes. When you sign up for credentialing with us, you get to choose exactly which panels you want, and don’t want, to be credentialed with.

Q: How can I track my insurance credentialing progress?

We provide client access to an online portal where you can always check the status of your project.  In addition, your Credentialing Specialist will reach out at regular scheduled intervals to provide personalized updates.  

Q: What if I don’t know which panels in my area are best for me?

We can help! One of our credentialing specialists will talk with you by phone and can help you to select the panels in your area that will be the best fit for you and your practice.

Q: What are some of the more popular insurance companies?

The popularity of insurance companies varies depending on location. However, some of the most popular and largest insurance companies are Aetna, Cigna, Magellan, Tricare, United Healthcare, Humana, Value Options/Beacon Health Options, Medicare, and many others.

Q: How long does the credentialing process take?

Q: How many hours of work does insurance credentialing take?

The amount of time that it takes to complete the credentialing process varies by license type.  For a standard outpatient practice, the Credentialing Team will put in between 10 and 12 hours of work for each insurance panel.  If an appeal has to be filed, that will add a minimum of 5 additional hours of work to that panel.

Facility-based services, Home Health Care Agencies, and DMEs will all take over 20 hours to complete the credentialing process.

Q: Have you ever credentialed or worked with providers in my area?

You bet! We have credentialed literally thousands of providers across the United States, including providers as far off as Alaska and Hawaii. No matter where your practice is, we have the experience needed to get you credentialed.

Q: Have you ever credentialed or worked with providers with my license type/specialty?

We have credentialed healthcare providers of more types than we can list: from chiropractors to behavioral health providers to surgeons. If you are eligible to be credentialed, we can get you credentialed!

If you are providing a service that is new and innovative, we also offer research with the insurance companies to see if your specialty is eligible for credentialing. This can save you hours of headaches reaching out to the individual insurance panels.

Q: Am I guaranteed to get on the panels I choose?

If you are fully licensed, we should have no problem identifying plenty of insurance companies and third party payers for you to be credentialed with. In some areas, some panels can be very selective or closed. In these instances, we will talk with you about the likelihood of a successful credentialing process. We want you to get the most out of your credentialing investment, but we cannot guarantee that insurance panels will accept you.

Q: What if the insurance panel I want to be credentialed with is closed?

Finding out a panel is closed can be frustrating. However, sometimes when panels say they are closed, they are still accepting providers, but on a limited basis. In the case of a panel saying that they are closed, we can and will submit an appeal when possible to the insurance company on your behalf. During an appeal, we will try to connect with the insurance company representative assigned to your area. We will then stress important parts of your qualifications and clinical practice. For instance, perhaps you have a specialty that the insurance company desires, or you are practicing in a neighborhood that is underserved. We do have success with many of our appeals. However, if a company is saying that their panel is closed, it might not be possible to get on the panel at that time.

 

Q: What if all the insurance panels are closed?

This situation is extremely rare as most insurance panels are consistently looking for new providers to add to their network. If panels are closed we will submit a formal appeal on your behalf when possible and advocate for you with the insurance companies.  During this appeal, we make a case as to why you are unique and why you should be allowed onto the panel. We have a very high success rate when it comes to appeal approvals.

Q: Can interns / limited-license providers be credentialed with insurance companies?

Sometimes, but it is highly unlikely. We have had success credentialing such providers on a limited basis—generally in areas that are very underserved. In most cases, insurance companies are looking to network exclusively with fully licensed healthcare providers. As an intern you can typically bill through a supervising provider.

Q: How long do I need to wait after getting licensed before I can get on insurance panels?

If you are a fully licensed provider most insurance companies will accept you right away even if you don’t have years of experience in the field. There are some panels that have certain regulations and may require a specific amount of experience. Your Credentialing Specialist will be able to help you navigate these requirements when recommending panels.

Q: Can I get credentialed with an EAP (Employee Assistance Program)?

Yes! Like insurance companies, EAPs are valuable third party payers to be credentialed with. The credentialing process is very similar to being credentialed with insurance companies. In fact, some of the major insurance companies also offer an EAP. Popular EAPs include: ComPsych, Optum, Magellan, Value Options, and Cigna.

Q: How much does credentialing cost?

We charge per panel, per provider that you apply to. We do not have any start up fees, hidden charges, or recurring monthly charges for your initial credentialing. You only pay for the work we do. Our pricing does vary by the type of credentialing you need. We have volume discounts if you enroll on more panels at a time. On the other hand pricing will be high if you enroll on only 1-2 panels initially. Call our Business Development Office at 855-664-5154 to get a quote.

 

Q: What is CAQH?

CAQH stands for Council of Affordable and Quality Healthcare.  It is a nonprofit that was created several years ago by the private insurance panels.  Most commercial payers require that you have the CAQH profile completed before you begin the credentialing process.  Panels use the CAQH to verify providers personal information as well as education and work history.

Q: Why is credentialing important?

Proper credentialing with the insurance panels is instrumental for operating an insurance-based practice. In order to bill efficiently and effectively, providers must be credentialed with each panel that they wish to bill. If the credentialing is not correct, your claims to the insurance panels can be delayed or even denied.

Q: What is a panel?

A panel is usually the equivalent of an insurance company. The term is commonly used to refer to a panel of plans. This is demonstrative of the fact that when a provider is on a panel he or she can bill for all of the plans under that panel.

Q: What is an NPI number?

Your NPI is a National Provider Identifier.  It is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).

The NPI 1 number identifies your license type, license level, and specialty.   Panels require that you have your NPI 1 before you begin the credentialing process.

Q: What is an NPI 1 and NPI 2 and do I need both?

An NPI 1 identifies you as the rendering practitioner, or the one providing the service. It’s like your social security number within the medical community. It follows you for the duration of your career. Regardless of who set up your profile, this identifier is unique to you. You take it with you wherever you work.

An NPI 2 is an organization identifier. It identifies the place you are providing the service. If you work for an agency this would be your employer’s company name and information. If you are in private practice this would be in your business name.

We recommend that anyone whose business has a tax ID acquire an NPI 2. From a credentialing perspective, this allows your contract with insurance panels to be at the organization level for applicable panels. Then your NPI 1 is linked to the NPI 2 for billing purposes. Therefore, your business is paid for your services. This becomes especially important as you grow your business and your team.

Additionally, some insurance panels like Medicaid, Medicare, and BCBS require the NPI 2 in order to credential with them if your business has a tax ID.

Q: When do Credentialing and Recredentialing occur?

Credentialing happens before a provider is considered eligible to participate in an insurance network. Recredentialing is done every 1-3 years after the original effective date of the provider to make sure that all of the information listed with the insurance panel are up to date and accurate.

Q: What organizations set credentialing standards and criteria?

The National Committee on Quality Assurance (NCQA) sets the credentialing standards and the specific state and federal regulations when it comes to Medicaid and Medicare participation.

Q: How do insurance panels gather credentialing data?

Many insurance panels will take the information from your CAQH profile in order to initiate the process. If a provider submits an application on the website for the respective panel, the application will go through the process and the panel will typically access your CAQH profile to verify the information on your application.

Q: How do I obtain a CAQH ID number?

Almost all insurance panels will require providers to have or obtain a CAQH ID. If you don’t already have one, we are able to create one for you! Let your specialist know that you’d like to have us complete an application for you and we’d be happy to add it to your project. Otherwise, please visit CAQH ProView to start the process.

Q: If I’m not approved, what happens next?

Unfortunately, we cannot guarantee that a provider will be accepting into the network as that power lies with the insurance panel. However, if you are not approved for participation, we will either follow through with an appeals process (if the panel has one) or we will wait until the next quarter to submit a new application.

Q: Why do I have to complete recredentialing?

Typically, once every three years, insurance panels require that you be recredentialed. This ensures that the information in their systems is current and accurate.

Q: Why would someone want credentialing?

Being credentialed with insurance panels means that you are able to see patients who have specific insurance plans and bill those insurance companies for the services you render. This can greatly increase the number of patients who can access your services.

Q: Do you have experienced credentialing providers in my area?

You bet! We have credentialed literally thousands of providers across the United States, including providers as far off as Alaska and Hawaii. No matter where your practice is, we have the experience needed to get you credentialed.

Q: Do you have experienced credentialing providers in my specialty?

We have credentialed healthcare providers of more types than we can list: from chiropractors, to behavioral health providers, to surgeons. If you are eligible to be credentialed, we can get you credentialed!

Q: What exactly is a panel?

Good question! When we use the term “panel,” we are using an abbreviation for insurance panel, which is the group of doctors who are networked with the insurance company and are able to provide services for patients that have that insurance. A panel could also be an EAP Panel, which is the same thing, but with an EAP (Employee Assistance Program).

Q: Do you provide medical billing?

Yes, we offer complete revenue cycle management services. To learn more please call 1-855-664-5154 or visit the medical billing section in our website.

Q: What is the process of Credentialing?

Physician Credentialing is the process of organizing and verifying a doctor’s professional records.

Q: How often does a provider need to be Credentialed ?

Healthcare providers need to be credentialed at least every three years. Some healthcare facilities or insurance companies perform recredentialing even more often.

Q: What is the Purpose of provider Credentialing ?

Facilitate practice by physicians and others in the hospital or healthcare system. Under federal and state laws and regulations.

Q: What do i need to have before starting credentialing?

You should have the following data before you start the credentialing business.

  • Obtain a Tax ID from the IRS under the legal business name.
  • Register for a Type 2 National Provider Identifier (NPI) and also Type 1 NPI.
  • Register for a bank account under the legal business name.
  • Search for a location to open your practice.
  • Obtain Malpractice Insurance.
  • Speak with our Credentialing Department to start the credentialing and contracting process

Q: How do you get your doctor credentialed ?

The following steps work to get doctors credentialed with insurance.

  • Get your NPI1 number.
  • Know how you are billing for your services.
  • Obtain malpractice insurance.
  • Complete the CAQH application.
  • Register with Medicare.

Q: What is the Credentialing and Privileging process ?

 The companion piece to credentialing is “privileging,” which is the process of authorizing a licensed or certified healthcare practitioner’s specific scope of patient care services. Privileging is performed in conjunction with an evaluation of an individual’s clinical qualifications and/or performance.

Q: What is a credentialing verification organization?

Credentials Verification Organization (CVO) Accreditation ensures a meaningful, rigorous, and fair credentialing process that protects both patients and providers from poor credentialing practices.

Q: What is meant by medical staff credentialing and why is it done?

Credentialing is the process obtaining, verifying, and assessing the qualifications of a practitioner to provide care or services in or for a healthcare organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications.

Q: How do I get credentialed by Aetna?

The provider needs to obtain an NPI and then register with CAQH. Submit an online application to Aetna with all supporting documents. Allow 30-60 business days to complete the credentialing process.

Q: How long is CAQH credentialing?

Every four months, you will receive a request from CAQH to re-attest that all of the information in your application is correct.

Q: What is provider enrollment and credentialing?

Provider Enrollment (or Payor Enrollment) refers to the process of applying to health insurance networks for inclusion in their provider panels. The Contracting phase of enrollment is when the provider has been approved by Credentialing and is extended a contract for participation.

Q: What is the credentialing process for nurse practitioners?

The nurse practitioners credentialing process involves the verification of education, licensure, certification, and reference checks. In order for a nurse practitioner to be eligible to bill government agencies and other commercial insurance companies, they must be credentialed. Initial credentialing involves a lot of paperwork.

Q: What is a CVO Accreditation?

Credentials Verification Organization (CVO) Accreditation ensures a meaningful, rigorous, and fair credentialing process that protects both patients and providers from poor credentialing practices.

Q: Do Physical Therapists need to be credentialed?

Yes, once physical therapists credentialed with any insurance provider will get all in-network payment benefits.

Q: What is vendor credentialing?

Vendor credentialing is the process by which companies and facilities ensure that the vendors they work with have the appropriate background and training to access their facilities.

Q: What is the universal credentialing in healthcare?

Council for Affordable Quality Healthcare (CAQH), a not-for-profit alliance of the nation’s leading health care plans and networks, has developed a single credentialing application and common application database. Instead of having to submit separate applications to each managed care organization, physicians can use the Universal Credentialing Data source system to submit a “universal” credentialing application either electronically or in hard-copy format.

Q: Can a provider have 2 NPI numbers ?

No, one provider has a single National Provider Identifier (NPI). Under a few circumstances group may have two NPI2. Because of multiple locations for the practice.

Call 855-664-5154 / E-mail at info@credentialing.com

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