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What is insurance credentialing?

What is Insurance Credentialing? 

Physicians and other healthcare practitioners such as a hospital, a counseling office, chiropractor, Dentist, Physical Therapist, Occupational Therapist, an optometrist’s office, Urgent care, Treatment center, Social worker etc, who wish to bill an insurance company as an in-network provider must undergo a process of credentialing.

Once a provider is credentialed with an insurance company, they can bill that company directly. In addition, most insurance panels will also provide “in-network” providers with referrals and preferential reimbursement rates. Many panels split the credentialing process into two parts. There is a credentialing phase and a contracting phase. During the credentialing phase, an insurance panel will perform primary source verification on a provider to make sure that the provider meets the minimum requirements of the panel. In addition, the panels may access the CAQH to assess the providers' education and employment history.

Once the credentialing phase is complete, the provider’s application will be sent to contracting. At this time, the provider and the practice may be offered an “in-network” contract with the panel. If they are offered a contract, it will usually include the fee schedule and CPT codes for which the provider is eligible to bill.

At Credentialing.com, we use the term credentialing to encompass both credentialing and contracting phases of the credentialing process. The credentialing specialists are trained to navigate both credentialing and contracting to ensure providers are properly on the panels.