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The Credentialing Process

Overview of Credentialing Process

Credentialing is a process that healthcare organizations and insurance companies use to verify the qualifications of healthcare providers. This process includes verifying a provider's education, training, licensure, and experience. The credentialing process is designed to protect patients and ensure they receive care from qualified providers. As I've discussed in another article, it includes the contracting portion. Once a clinic or individual provider becomes credentialed with an insurance company, the clinic/provider can submit claims for their services.

The credentialing process typically involves the following steps:

  1. The provider applies to the organization or payer. This application typically includes the provider's name, address, contact information, education, training, licensure, and experience. If applying for a clinic and individual provider(s), insurance companies can require one application for the clinic and one for each provider. 

  2. The organization or payer verifies the provider's information. This verification process may involve contacting the provider's educational institutions, licensing boards, and previous employers. At this stage, it is common for insurance companies to request more information from the clinic and individual providers if it still needs to be provided along with the application or if they need further verification. 

  3. The organization or payer reviews the provider's information. This review will assess the provider's qualifications and determine whether they meet the organization's or payer's standards. The insurance will also look at where the provider is offering services to see if that area is too saturated with the provider's specialty type or if it is an area that needs more of that specialty type. 

  4. The organization or payer makes a decision. They will be approved if the provider meets the organization's or payer's standards and the area needs the provider's specialty/services. If they do not meet the standards, they will not be approved and thus not credentialed. If the denial is due to the area not needing the services offered, the insurance company will typically hold the application for three months to a year. The insurance company will push the application through should the area need those services again.

The credentialing process can be time-consuming and complex. It is important to note that the credentialing process differs from the privileging process. Privileging is the process that healthcare organizations use to allow providers to perform specific procedures and services at their facility.

Reasons insurance companies credential clinics and providers.

  • It helps to ensure that patients are receiving care from qualified providers.

  • It helps to protect healthcare organizations and payers from liability.

  • It helps to improve the quality of care.

  • It helps to reduce costs.

Doing your part in the credentialing process.

Here are tips for navigating the credentialing process:

  • Start early. One mistake owners and providers make is waiting to begin the credentialing process. They wait too close to when they want to start offering services or when the clinic opens. The credentialing process can take 30 days to nine months or more to complete, so it is essential to start early. Each insurance company and each state has its requirements and specific processing standards. This can result in some applications processing faster than others in different states or different processing speeds in the same state but with various insurance companies.

  • Be organized. Please keep track of all documentation and submit it to the organization or payer promptly. Submitting the correct information from the start helps the process go smoother and faster.

  • Be responsive. Respond to any requests for information promptly. The more responsive you are, the more your application stays at the top of the pile for processing.

  • Follow up. If you are still waiting to hear back from the organization or payer within a reasonable time, follow up with them. Often, applications can get lost, put on the back burner, or have yet to be seen. Calling and staying in contact helps the reps focus on your application and can save time if the application gets lost and needs to be resubmit. 

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