What is the insurance credentialing process?

The insurance credentialing process is what each provider or facility must go through in order to become a participating provider with a particular insurance company.  The goal of the insurance credentialing process is to become in-network and prevent your patients from having claims go towards their out-of-network deductible. The credentialing process starts by making a request to join the insurance company’s network and submit your information to them.  Most of the large insurance companies utilize CAQH to access your license, DEA, CV, W9, etc.  Once this request has been submitted, the payer typically takes about 30 days to review your information and determine if they wish to proceed with the credentialing process.  (Primarily for new practices- If they do wish to proceed, you’ll be notified that they have a closed panel for your specialty or are not writing any new contracts in your area.  If this happens, your recourse is to appeal their decision and substantiate the need for them to contract with you by providing additional information about your skills and the area you plan to serve.)  If they do wish to move forward, this is the stage where the payer (insurance company) validates your information and ensures you are who you say you are.  Once through this initial validation process happens referred to as primary source verification, you then transition into the contracting phase.  If you’re joining an established group, this is where you are linked to their group contracts through and addendum or roster depending on the payer and size of the group . If you’re setting up a new practice, this is where the payer submits a contract to you for review.  The initial credentialing process (data validation) typically takes around 90-120 days for most commercial payers.  The contracting phase, on average take another 30-60 days depending on the company, specialty and your location.  South Florida or Los Angeles is going to be slower than a small town in most cases.  As you can see, the insurance credentialing & contracting process varies for new practices vs established groups adding a new provider.  To ensure you’re equipped with the most accurate information, we’ve put together two documents detailing the process and some of the differences.  The primary difference for a new practice involves contracting which is separate but just as important as credentialing.

1. New Practice- Credentialing & Contracting Process

2. Established Practice- Credentialing & New Provider Enrollment Process

What is our credentialing process like?

Once you sign with us you will be sent a link where you can complete the online enrollment process.  We do not just fill out paperwork and hope for the best.  Your assigned account manager diligently works on your behalf to get you on all of the panels as quickly as possible.  We track each application and utilize our relationships (developed through the credentialing of 1000s of providers) to do our best and quickly advance the credentialing/contracting process. For a provider switching EINs but remaining in the same area, the commercial carriers take on average around 30-45 days but Medicare still takes 90-120 days.  Some of the commercial carriers are very slow but as a rule your slowest payers are Tricare, Medicare, and some state Medicaid programs. Our Step-by-Step Physician Credentialing Process 1) Week 1 Strategy and Information Gathering a)     During the first ten days or so after signing an agreement, our team will work with you to massage your payer list and ensure all relevant payers are included. b)     In addition to the payer review, your account manager will work with you to ensure we have everything needed to submit and process your applications. 2) Weeks 2-5 Application Submission & Follow up a)      During this time we will contact all insurance companies and begin the application process.  Some of them require an LOI (letter of interest) and others want you to submit a form on their website.  Regardless of how they do it, we will take care of all of this. b)      Once the requests to join the network have been submitted, this is when the follow-up process starts and continues until everything has been finalized. 3) Weeks 6-9 Follow-Up & Contracting a)      During this period we will continue to follow up and should begin to see your application making it through the payers credentialing process. b)     Once your application has made it through the initial process, we will now ensure it transitions smoothly into the contracting phase. 4) Weeks 10-16 Contract Negotiations & Effective Dates a)      This is when things start to get fun.  Agreements are coming in and you’re beginning to see some results.  Payer agreements are reviewed and submitted to you for signature (if they don’t need to be negotiated).  Once signed, these executed agreements are returned to the payer for loading.  The loading process with some payers can take an additional 30-45 days. b)      Finally, we will work through your payer list and ensure we have effective dates and provider IDs for all applicable payers.  We will then work with you to provide this information to your billing company or department.