Frequently Asked Questions

Frequently Asked Questions

Medical credentialing can be both confusing and overwhelming, but it doesn’t need to be!

Credentialing FAQ – Medical Credentialing, Provider Enrollment

Below are answers to a some Frequently Asked Questions about credentialing.  In addition, we’d be happy to answer your specific questions! Contact us anytime at 209-232-6222 , 209-208-5666.

Frequently Asked Questions

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.

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.

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 Blue Cross, Blue Shield, Aetna, Cigna, Magellan, Tricare, United Healthcare, Humana, Coventry, Highmark, Health Net of California, Kaiser, Wellpoint, Wellcare, Regence Group, Value Options, Medicare, and many others.

How many hours of work does insurance credentialing take?

The amount of time it takes for insurance credentialing can vary depending on factors such as the number of insurance companies you are applying to, the completeness of your application, and the time it takes for the insurance companies to complete their verification process. On average, it can take anywhere from a 90  weeks to 120 days to complete the credentialing process. The amount of time spent on the process itself can vary from several hours to several days, depending on the complexity of the application and the level of support you receive from a credentialing service.

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!

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

Finding a closed panel 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 still submit an appeal 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.

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

Sometimes, but it’s 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.

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

The waiting period after getting licensed before you can get on insurance panels varies depending on the insurance company. Some may allow you to apply as soon as you receive your license, while others may require you to wait a certain amount of time, such as 90 days or more, before applying. 

What is an NPI number (an NPI 1, and an NPI 2)?

There are two types of NPI numbers: NPI-1 and NPI-2. NPI-1 is the standard NPI number that identifies an individual healthcare provider. NPI-2 is an identifier for Group/Organizations providers that can be used to distinguish between providers with the same name, or to identify providers who work in multiple locations or specialties.

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, OptumHealth, Magellan, Horizon Health, Mines and Associates, ValueOptions, Cigna, and Harris-Rothenburg International.

How can I track my insurance credentialing progress?

By using our medical credentialing service we handle the entire Credentialing and Provider Enrollmetnt  process for you and provide regular biweekly updates on the status of your credentialing with each insurance company though dedicated crm panel.

What is the process for getting credentialed with Tri-care?

The process for getting credentialed with Tricare program. Generally, providers must complete an application, provide supporting documentation (such as proof of licensure, malpractice insurance, and credentials), and complete a site visit or virtual inspection. Tricare may also require additional training or background checks depending on the type of provider and the services offered.

 It is important to note that the credentialing process can take several months, so it is recommended to begin the process as soon as possible.

DIY Credentialing: the number one challenge:

The number one challenge with DIY credentialing is the complexity of the process. Credentialing involves navigating a range of different requirements and regulations from various insurance companies and government agencies. This can be time-consuming and confusing, particularly for those who are unfamiliar with the process. Additionally, mistakes or omissions can result in lengthy delays or rejections, which can be costly and frustrating. As such, many healthcare providers choose to outsource the credentialing process to experienced medical Credentialing companies like us  who can navigate the complexities of the system efficiently and effectively.

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How often does a provider need to be credentialed?

Healthcare providers need to be credentialed at least every three years for Medicare. Some healthcare facilities or insurance companies perform re-credentialing even more often.

How do I start a credentialing business?

 You should have the following data before you start the credentialing business.
1. Obtain a Tax ID from the IRS under the legal business name.
2. Register for a Type 2 National Provider Identifier (NPI) and also Type 1 NPI.
3. Register for a bank account under the legal business name.
4. Search for a location to open your practice.
5. Obtain Malpractice Insurance.
6. Speak with our Credentialing Department to start the credentialing and contracting process..

What is the credentialing and privileging process?

The credentialing and privileging process is a comprehensive evaluation of a healthcare provider’s qualifications and professional background. It is designed to ensure that providers meet specific standards of competence and ethical conduct before they can provide medical services at a hospital or other healthcare facility. The process involves verifying a provider’s education, training, licensure, certifications, work history, and malpractice insurance, among other criteria.

Once a provider has been credentialed, they can apply for privileges, which are specific clinical activities or procedures that they are authorized to perform at a healthcare facility. The privileging process involves evaluating a provider’s clinical skills, experience, and training to determine which privileges they are qualified to perform. The process is typically managed by a credentialing committee or medical staff office at the healthcare facility.

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

Credentialing is the process of 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.

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.

What is the universal credentialing in healthcare?

There is no single “universal credentialing” process in healthcare. Credentialing requirements and processes vary depending on the type of healthcare provider, the organization or facility they work for, and the insurance companies they work with. However, there are some common elements to credentialing, such as verifying a provider’s education, training, licensure, and certification, as well as conducting background checks and verifying insurance coverage. The Council for Affordable Quality Healthcare (CAQH) offers a universal provider data source that aims to streamline and simplify the credentialing process for providers and health plans

What is vendor credentialing?

Vendor credentialing is a process in which healthcare facilities verify and validate the qualifications and credentials of vendors and their representatives who provide goods and services to the facility. The purpose of vendor credentialing is to ensure that vendors and their representatives meet the same standards as healthcare providers and staff, in terms of qualifications, training, and background checks, to ensure patient safety and regulatory compliance. Vendor credentialing typically involves the collection and review of documentation such as licenses, certifications, insurance, and other compliance requirements, as well as ongoing monitoring and maintenance of vendor records.

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.

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.

What is the credentialing process for nurse practitioner's?
The nurse practitioner’s 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
What is the process of getting credentialed with insurance companies?

Getting credentialed with insurance companies involves several steps, which may vary depending on the insurance company’s requirements. Generally, the process involves the following:

  1. Gathering documentation: The first step is to gather all the necessary documents, such as your medical license, DEA registration, malpractice insurance, and board certification, if required.

  2. Submitting the application: Once you have gathered the necessary documentation, you can submit your application to the insurance company. The application will typically include your personal information, practice information, and details of your education, training, and experience.

  3. Provider enrollment: After submitting the application, the insurance company will review it and may contact you for additional information or to clarify any details. Once your application is approved, you will need to complete the provider enrollment process, which includes signing contracts and agreements.

  4. Credentialing: The insurance company will then verify your credentials, which may involve checking your education, training, experience, and other qualifications. This process may take several weeks or even months.

  5. Approval: Once the insurance company has verified your credentials, you will receive approval to participate in their network and can start seeing patients covered by their plans.

It’s important to note that the credentialing process can be complex and time-consuming, and the requirements can vary between insurance companies. It’s often helpful to work with a medical credentialing service to ensure that your application is complete and accurate and to streamline the process.

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 best fit for you and your practice.

How long does the credentialing process take?

The credentialing process generally takes between 90-120 days. When you sign up for credentialing with us, we waste no time getting your applications completed and submitted to insurance companies. We then follow up regularly with insurance companies to make sure that your credentialing applications are processed and approved as soon as possible.

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.

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!

What if all the insurance panels are closed?

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!

Can an intern bill patients under a supervising provider?

In general, interns may be able to bill patients under a supervising provider, but this may depend on the specific laws and regulations in the state or country where the practice is located. Some states or insurance companies may have specific requirements for billing and reimbursement when services are provided by interns, such as requiring the supervising provider to be present during the service or requiring that the billing be done under the supervising provider’s NPI number.

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).

What is CAQH?

CAQH is a non-profit alliance of health plans and related organizations that focuses on simplifying healthcare administration. It operates a universal credentialing database called CAQH, which allows healthcare providers to submit and maintain their professional and practice information in one place. Health plans and other healthcare organizations can then access this information to credential providers and manage network participation. Using CAQH can streamline the credentialing process for providers and help reduce administrative burdens for all parties involved in healthcare.

How much does credentialing cost?

The cost of credentialing can vary depending on several factors such as the number of insurance companies you want to be credentialed with, the complexity of your practice, and the level of assistance you need. The costs can range from a few hundred to a few thousand dollars. It’s best to consult with our Credentialing Specialist or schedule a call   to get an estimate based on your specific needs.

Can an LMHC accept Medicare?

 Licensed Mental Health Counselors (LMHCs) are eligible to enroll as Medicare providers and bill for their services. However, there are certain requirements that need to be met, such as obtaining a National Provider Identifier (NPI) number, being licensed to practice independently in the state where the services are provided, and submitting an enrollment application to Medicare. It’s important to note that not all LMHCs may choose to accept Medicare due to the reimbursement rates and other factors.

Can providers with a disciplinary action on their record still be paneled?

It depends on the specific details and severity of the disciplinary action. Insurance companies have different policies and criteria for credentialing providers, and a disciplinary action may impact the provider’s ability to be paneled. It is best to consult with our Credentialing Specialist team to determine the impact of a disciplinary action on the paneling process.

DIY Credentialing: the challenge of “missing” information:

One of the biggest challenges of DIY credentialing is the possibility of missing information. Credentialing involves a lot of paperwork and documentation, and missing even one piece of information can cause delays in the process. Without a thorough understanding of the requirements and necessary documents, it can be easy to overlook important details. This can result in wasted time, frustration, and potentially lost revenue if the provider is unable to bill insurance companies until the credentialing process is complete. We have the Solid Knowledge of each and every regulations and law to get the provider on-board with the insurance panels ASAP.

For Physicians: do I need to be “Board Certified” to get on insurance panels?

Being “Board Certified” is not always a requirement to participate in insurance panels as a physician, but it may depend on the specific insurance companies and their policies. Some insurance companies do require physicians to be board certified, while others may only require a valid medical license and malpractice insurance.

However, it is important to note that being board certified can demonstrate to patients and insurance companies that you have met rigorous professional standards and have a high level of expertise in your field. Additionally, some insurance companies may offer higher reimbursement rates or other incentives for physicians who are board certified. Ultimately, the decision to become board certified is up to you and may depend on your professional goals and the requirements of the insurance panels you wish to join.

What is the process of Physician credentialing?

The process of Physician credentialing typically involves the following steps:

  1. Gathering information: This includes collecting all necessary information about the healthcare provider, such as their education, training, work history, licenses, certifications, and insurance.

  2. Verifying information: This step involves verifying the accuracy and validity of the information provided, typically through primary source verification (PSV) from the relevant issuing organizations.

  3. Assessing qualifications: Once the information has been verified, the healthcare provider’s qualifications and credentials are evaluated to determine whether they meet the requirements for the desired insurance networks, hospitals, or other healthcare organizations.

  4. Application submission: The healthcare provider then submits their application to the relevant insurance networks, hospitals, or other healthcare organizations.

  5. Review and approval: The application is reviewed and evaluated by a credentialing committee or other relevant entity, which then makes a decision on whether to approve or deny the provider’s application.

  6. Ongoing maintenance: Once a provider has been credentialed, they must maintain their credentials by keeping their information up-to-date and undergoing periodic re-credentialing.

What is the purpose of provider credentialing?

The purpose of provider credentialing is to verify the qualifications, training, experience, and background of healthcare providers to ensure that they meet the standards necessary to participate in healthcare plans and provide quality patient care. The credentialing process also helps to protect patients, healthcare providers, and insurance companies from fraudulent or unqualified providers, and it ensures that healthcare providers maintain high standards of professional practice. Additionally, the credentialing process helps to streamline administrative processes, such as billing and insurance claims, by providing accurate and up-to-date information about healthcare providers.

How do you get your doctor credentialed?

The following steps work to get doctors credentialed with insurance.
1. Get your NPI1 number.
2. Know how you are billing for your services.
3. Obtain malpractice insurance.
4. Complete the CAQH application.
5. Register with Medicare.
6. Contact each insurance company with which you want to be in-network.

How long is CAQH credentialing?
The length of time it takes to complete CAQH credentialing can vary depending on factors such as the completeness and accuracy of the application, the timeliness of responses to any follow-up requests for information, and the processing time of the individual health plans or insurance companies. However, typically, the CAQH credentialing process takes anywhere from 4-12 weeks to complete.
Do Physical Therapists need to be credentialed?

Yes, physical therapists need to be credentialed in order to be recognized as providers by insurance companies and receive reimbursement for their services. The credentialing process verifies their education, licensure, and other qualifications to ensure they meet the standards required by insurance companies.

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

Medical staff credentialing is a process that healthcare organizations use to ensure that their medical staff members, such as physicians, nurse practitioners, and physician assistants, are qualified to provide patient care. This process typically involves verifying a provider’s education, training, work history, licenses, certifications, and other credentials.

The purpose of medical staff credentialing is to protect patient safety and ensure that healthcare providers are qualified to provide medical care. By verifying a provider’s credentials, healthcare organizations can ensure that the providers they hire have the necessary education, training, and experience to provide high-quality care to their patients. Additionally, medical staff credentialing helps to ensure that providers meet the standards set by regulatory bodies and insurance companies, which is important for obtaining reimbursement and maintaining compliance with regulations.

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