Credentialing

Credentialing Services offers hassle free profitable solutions for providers

The credentialing process is very complex and follows many steps in order for providers to gain the privilege to provide services at the facility in which they are employed in addition to seeing patients covered under certain insurance carriers. Credentialing is happening on a continuous basis by doing research, responding to and maintaining files critical for credentialing, executing revalidations, and much more. As with any complex procedure, credentialing has a starting point in which providers are enrolled with insurance carriers, provider enrollment.

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Provider Enrollment is the process of becoming a participating provider with an insurance carrier, some insurance carriers will have an enrollment application to be completed. In lieu of an application, some carriers utilize CAQH, therefore it is extremely important that a provider’s CAQH profile is kept up to date and attested regularly. Examples of necessary documents for sub-mission of the application are professional license copies and educational diplomas or transcripts.

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Credentialing verifies a licensed professional’s qualifications and work history. The primary source verification process includes, but is not limited to, evaluating the education, professional training, malpractice insurance, certifications, work history and any gaps in that work history.

Another piece to the whole credentialing process is the contracting phase. After the provider has requested participation and passed the primary source verification, the carrier may send out contracts. Once the contracts are executed, the provider is as-signed an effective date.

Insurance carriers have different requirements for credentialing. Some may only require provider enrollment where others require provider enrollment, credentialing and contracting. Some carriers may go retroactive, or back date, when as-signing their effective date where others assign an effective date when the entire process is complete. Depending on the carrier, this process can be completed anywhere from 10 days to 6 months from the time the carrier receives a clean application.

The credentialing process can also vary depending on the plans within an insurance carrier. Please see the chart below for an example, BCBSM Traditional, BCBSM Managed Care Lines of Business and Blue Care Network. The process for all of these plans is initiated by one application submitted to the BCBSM Provider Enrollment Department.

With over 30 years experience in credentialing, we can improve your bottom line. Contact us for a free assessment on how to increase your department's revenue.