Credentialing vs Contracting

What's the difference?

Credentialing and contracting are two separate but related processes that healthcare providers must go through to enroll with an insurance company. To contract with an insurance company, a healthcare provider must first be credentialed by that insurance company. The provider must have met the insurance company's credentialing requirements. The person in charge of the credentialing must know the current requirements to credential a provider with the insurance company. Once approved, the provider can provide services to patients and receive payment from insurance companies.

Some insurance companies keep the credentialing and contracting processes separate. They will credential a provider, and if that provider passes the credentialing stage, then they will write a contract for that provider. More recently, insurance companies have combined credentialing and contracting into one process. It's common to refer to the entire process of credentialing and contracting as "credentialing." 

Credentialing is the process of verifying a healthcare provider's qualifications and experience. This includes checking their education, training, licensure, and other relevant information. The insurance company will use the provider's NPI and CAQH accounts to help validate and verify the provider. They will confirm that the provider is licensed to provide the services they request in a contract. The provider's NPI and CAQH must be up-to-date and accurate to prevent delays and denials.

Contracting is the process of signing a contract with an insurance company. The contract outlines the terms and conditions for the provider to provide services to the insurance company's members. The contract will typically specify the types of services the provider is authorized to provide, where the services will be provided, the plans the provider is approved for, the rates they will be paid, and any other relevant information. 

The provider is considered out of network (OON) during the credentialing process. When the provider receives a contract listing the plans they are in network with and the contract's effective date, they can begin providing services to the insurance company's members. If a provider sees members before receiving an effective date, then that provider might not be able to bill those dates of service and thus lose money.

It is important to note that credentialing and contracting are ongoing processes. Providers must maintain their credentials and comply with the terms of their contracts to continue providing services to insurance company members. A provider's NPI, CAQH, Availity, and any other sites/portals used for credentialing must be updated. 

A credentialing specialist will ensure that the information submitted to the insurance company is accurate and up-to-date. They should also monitor all sites and portals relevant to credentialing throughout the process. Provide accurate and current information to avoid delay and denial of the application.