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A credential provider gets an increased number of patients through referrals from
payers. Further, credentialing assures the patient that they are getting treated by a
credible provider. It also helps physicians expand their business. Physicians/providers
must credential themselves, i.e., enroll and attest with the payer’s network and get
authorized to provide services to patients who are members of the payer’s plans.
Steps to File Credentialing Applications accurately
A good provider application is the first step to success in the credentialing process. A provider himself can fill this application, or he/she can outsource this process to an experienced Credentialing specialist. An accurate application will consist of all details, including:
Provider start date in practice
• Copy of state license
• Copy of DEA
• Provider DOB and SSN
• NPI #
• Updated CV- work history
• NPPES logons
• CAQH logons
• Malpractice incidence details
• Copy of Degree/Diploma certificates
• Copy of Driving License
• Group Name
• GNPI & Tax id
• Practice and billing address along with Phone and Fax #
• Signed W9
Steps to File Credentialing Applications accurately
A good provider application is the first step to success in the credentialing process. A provider himself can fill this application, or he/she can outsource this process to an experienced Credentialing specialist. An accurate application will consist of all details, including:
Provider start date in practice
• Copy of state license
• Copy of DEA
• Provider DOB and SSN
• NPI #
• Updated CV- work history
• NPPES logons
• CAQH logons
• Malpractice incidence details
• Copy of Degree/Diploma certificates
• Copy of Driving License
• Group Name
• GNPI & Tax id
• Practice and billing address along with Phone and Fax #
• Signed W9
CAQH stands for “Council for Affordable Quality Healthcare.” It is an online database that
stores provider information. Providers grant access to their data to insurance companies
through CAQH, making acquiring provider information more manageable. Almost all of
the National Health Insurance Companies use CAQH, which makes it a prerequisite for
their enrollment process.
There are three steps to getting set up in CAQH.
Obtain your CAQH ID (within 2-3 business days)
• Set up your secure username and password
• Complete the online application and send in the required documentation
• Send your attestation for signature, which certifies the application
• Grant insurance companies access to your online application Not having a completed, up-to-date CAQH application will delay your enrollment with the insurance companies. Furthermore, this will prevent you from getting reimbursed for your services.
There are three steps to getting set up in CAQH.
Obtain your CAQH ID (within 2-3 business days)
• Set up your secure username and password
• Complete the online application and send in the required documentation
• Send your attestation for signature, which certifies the application
• Grant insurance companies access to your online application Not having a completed, up-to-date CAQH application will delay your enrollment with the insurance companies. Furthermore, this will prevent you from getting reimbursed for your services.
After submitting the provider credentialing application to the payers, the Provider or the
credentialing team should ensure that they follow-up once in 5 days. Frequent follow-ups
enable you to catch applications with errors or rejected applications faster and re-submit
them in a short span.
A successful Credentialing approval is followed by a process that associates the physician
with the payer’s network. This process is known as Payer Contracting. Typically, the
payer will share the standard reimbursement rates and the traditional plans such as
HMO, PPO, WC, and Auto insurance. While contracting, a provider should ensure that
he/she:
• Is adopting an insurance plan that is suitable for his/her business
• Negotiates a fair reimbursement rate for the services provided
• Appeals to open the panels of the networks that are closed for new providers
• Is adopting an insurance plan that is suitable for his/her business
• Negotiates a fair reimbursement rate for the services provided
• Appeals to open the panels of the networks that are closed for new providers
Importance of Maintaining Provider Data Insurance directory Submissions
Providers must keep their details and contact information updated in the provider directory to provide accurate information to the patients. A provider should insist on including these details while completing the insurance directory verification and edit the information as & when required:
• Provider name and educational qualifications
• Practice Specialty with board certification details
• The legal business name that he/she has been practicing with currently
• The correct phone number for booking appointments or clarifying any other queries
A practice running a group facility with more than one physician should consistently
update any additions or deletions in the group for un-hindered reimbursements. The
practice administrator should report:
• Any addition of new Physicians / Mid-level providers to the provider group for addition to the contract as well as the insurance directory
• Any deletion of existing providers from the group for removal from the contract & the insurance directory
• Any addition of new Physicians / Mid-level providers to the provider group for addition to the contract as well as the insurance directory
• Any deletion of existing providers from the group for removal from the contract & the insurance directory
The significance of maintaining provider information lies in ensuring that provider
information is updated as needed. A practice must ensure that all Provider’ information,
such as contracted payment terms, name, address, tax id number, and newly gained
certifications, is kept current. With medical technology advancing at rocket speed, healthcare facilities see no end to their exponential growth in size and capacity. While largely overlooked, the key to hospitals performing with quality care and professionalism is the rigorous behind-the scenes work of their medical staff, making physician credentialing to hospitals’ uninterrupted operations.