Insurance Credentialing Checklists

This is a great place to start if you are working on your credentialing with the insurance companies.  We also provide the checklist and enrollment form we use if you have engaged our services.  There are primarily two scenarios that you will encounter when approaching the insurance credentialing process which we cover.  We have provided two different checklists depending on your scenario.  One should be used if you are an established group that has hired a new provider and the other is for a new practice.

1. Established Group- New Provider Credentialing Checklist

Download Checklist New Provider CHecklist

 

 

Scenario 1: Utilized if credentialing a new medical provider under an established group
1 Updated and attested CAQH profile- you will need to list your new practice affiliation in CAQH including your start date.  You need to be sure that your license and DEA are updated to the new state you will be working in, if you’re being affiliated with a group in a new state
2 Group needs to provide a list of payers they are currently contracted with,  This should include the commercial, Medicare advantage plans, Medicaid HMOs, workers compensation, Tricare and any TPAs the group is affiliated with.
3 Tax ID (W9 with pay-to address and CP 575/147 C letter for group).  You will need to supply this to insurance companies and upload to your CAQH profile.
4 Hospital credentialing is required for some specialties/payers and you need to identify in CAQH which hospitals you plan to have privileges with.  If you do not have hospital privileges, establish an ‘admitting arrangement’ with another provider in your area, or determine which hospitalist group/ER you will use for admitting arrangements.
5 New malpractice policy or updated to current policy include your new employment.  This will need to be uploaded to CAQH.  Needs to list provider out as named insured on certificate, not just be a policy in the group’s name.
6 You will need the group’s primary billing(type II NPI).  This will be listed on your applications along with the group’s tax id.
7 Group’s Medicare PTAN that you will be linked to.  This will need to be listed in your Medicare application to link to the new group
   
 

List of required documentation/information for adding new provider(s) to existing practice:
• Professional state license
• DEA cert (if applicable) or covering provider name (if none).  **If DEA is in a state other than the one provider is applying for, need to move DEA to new/current state**
• CDS cert (if applicable)
• Board certification or proof of board eligibility
• PLI certificate (must have exp date >60 days in future @ all times in cred process)
• Professional school diploma
• Certificates of completion for any internships/residencies/fellowships
• CAQH login and pw (if no CAQH, need: name, DOB, SSN, home address and city/state of birth)
• PECOS login and pw
• State Medicaid system login and pw (if applicable)
• Availity system login, pw, and backup codes
• CURRENT CV, with all begin/end dates for education/training listed as EXACT dates (day/mo/yr), not just mo/yr.
• Hospital admitting privileges or covering provider.  If provider has their own privileges, need hospital name, staff status/category (active staff, consulting staff, courtesy staff, etc), as well as appointment date.

2. Credentialing Checklist- New Practice

Download New practice Credentialing Checklist
 

Scenario 2: This checklist should be used if you are opening a new medical practice.
1 You will need to first establish your new group in your state.  You will need to obtain your tax id through the IRS which can be done online here: https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online- 
2 Make sure to download the electronic file available when obtaining your EIN which is called a CP-575
3 You now need your service address.  It may seem early but unfortunately, you will need this to complete the credentialing process.
4 Once you have completed your business registration process, obtained your tax id, and found your service location, you can now apply for your Group NPI which can be done here: https://nppes.cms.hhs.gov/#/.  We can also do this for you, as long as we have your PECOS/NPPES login and pw.  If you don’t know the login and pw, you can recover/reset them by calling PECOS/EUS help desk @ 866-484-8049.
5 Updated and attested CAQH profile.  If you don’t have a CAQH ID or are unsure what CAQH is, you can learn more here about the registration process here: https://physicianpracticespecialists.com/services/caqh-registration/.  You can also call the CAQH help desk @ 888-599-1771 to recover and reset your information.
6 You will need to identify which payers you plan to credential with.  These should include all commercial PPOs/HMOs, Medicare advantage plans, Medicaid HMOs, workers compensation, Tricare and any TPAs/IPAs/MSOs that are active in your area which you hope to be affiliated with.
7 Complete a W9 with your billing/pay-to address identified.  This should have your new entity’s information on it, not your personal info.  You can download a w9 here: https://www.irs.gov/pub/irs-pdf/fw9.pdf
8 Hospital credentialing is required for some specialties and is required by insurance companies at the time of credentialing.  You at least need to have the credentialing process underway with a hospital in your area or have a covering provider/hospitalist group/ED lined up for hospital admissions.
9 You will need a PERMANENT office phone/fax which will be listed in CAQH and on your applications.  Using your cell or a temporary # you are planning to update later on is not recommended as this phone number will be used in public directories and is what patients will call when scheduling an appointment (and will require additional app forms to update/edit @ a later date).  We recommend efax solutions such as Ringcentral or eFax
10 You will need to obtain a malpractice policy.  This is not required for Medicare but is a requirement for commercial insurance companies.  You can oftentimes get a start date that reflects when you will open so you’re not paying for something you won’t be using.  You need to be sure there isn’t a lapse in coverage if you can help it and if your current employment is utilizing a claims-made malpractice policy.  This new malpractice policy will need to be uploaded to CAQH.
11 When updating and attesting your CAQH profile, remember to authorize insurance companies access to your profile which is an option you should check.
12 We will need the following documents/information for the practice, should you wish to apply with Medicaid: business license, articles of incorporation, group/practice’s general commercial liability insurance and worker’ s comp insurance, CLIA cert (or clia waiver), if applicable.
13 Once you have confirmed that you have all of this in place, you are now ready to start contacting payers, submitting applications and letters of interest.  Some payers allow you to initiate the process over the phone (make sure to get a reference number), others are online while there are still some that want you to download an application and email/mail it in.  Medicare applications should be done online through PECOS while Medicaid enrollment is handled at the state level with each one having their own proce
   
 

List of required documentation/information for new practice:
• CP 575 or 147C letter
• Signed w-9
• Business license (if not req’d for your service area, please let us know this)
• Ficticious name permit (some states do not require this)
• Articles of incorporation or organization(depending if you started an LLC or Corp)
• General/commercial liability insurance coverage
• Worker’s comp insurance coverage for practice
• CLIA cert (if applicable) or CLIA waiver
• EFT verification letter (from bank) or voided check: Here is an example of the bank letter needed for Medicare: https://physicianpracticespecialists.com/tools/medicare-bank-letter-template/
   
 

List of required documentation/information for provider(s) @ new practice:
• Professional license
• DEA cert (if applicable) or covering provider name (if none).  **If DEA is in a state other than the one provider is applying for, need to move DEA to new/current state**
• CDS cert (if applicable)
• Board certification or proof of board eligibility
• PLI certificate (must have exp date >60 days in future @ all times in cred process)
• Professional school diploma
• Certificates of completion for any internships/residencies/fellowships
• CAQH login and pw (if no CAQH, need: name, DOB, SSN, home address,and city/state of birth)
• PECOS login and password
• State Medicaid system login and pw (if applicable)
• Availity system login, pw, and backup codes (if applicable)
• CURRENT CV, with all begin/end dates for education/training listed as EXACT dates (day/mo/yr), not just mo/yr.
• Hospital admitting privileges or covering provider.  If provider has their own privileges, need hospital name, staff status/category (active staff, consulting staff, courtesy staff, etc), as well as appointment date.

Our Provider Credentialing Checklist

If working with us to complete the credentialing process, here is our credentialing checklist which has a link to our online form which should be completed for each provider within the group. Once you sign-up for our services, you will receive an invitation to your secure collaboration folder within 24 hours. This is where you can upload the required documents and provide your login information for CAQH & PECOS (as needed).

In addition, you may or may not have your group (type II) NPI but that’s quite alright because we will obtain this for your new organization.

Download Our Credentialing Checklist