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 toward their out-of-network benefits. The credentialing process starts by making a request to join the insurance company’s network and submitting 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 (insurance company) typically takes about 30 days to review your information and determine if they wish to proceed with the credentialing process. Something that happens primarily with new practices is that if they do not 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.  This is your attempt to show the insurance payer how your practice is unique and why they need to consider adding you to their network.

If they do wish to move forward, this is the stage where the payer validates your information and verifies you are who you say you are. Once you are through the initial validation process, also referred to as primary source verification.  Once all verifications have been completed and the payer determines the need to have you in the network, 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 an 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 takes another 30–60 days depending on the company, specialty, and location. South Florida or Los Angeles is slower than a small town in most cases. The insurance credentialing and contracting process varies for new practices versus established groups adding a new provider. The primary difference for a new practice involves contracting, which is separate but just as significant as credentialing. To verify you’re equipped with the most accurate information, we’ve put together two documents detailing the process and some of the differences:

1. New Practice- Credentialing & Contracting Process

2. Established Practice- Credentialing & New Provider Enrollment Process

What Is Our Credentialing Process Like?

Once you sign up with Physician Practice Specialists for credentialing services, 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 thousands 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 some may take 90–120 days. 

Our Step-by-Step Physician Credentialing Services Process

Week 1: Strategy and Information Gathering

During the first ten days or so after signing an agreement, our team will work with you to massage your payer list and verify all relevant payers are included. Along with the payer review, your credentialing services account manager will work with you to check that we have everything needed to submit and process your applications. 

Weeks 2–5: Application Submission and Follow Up

During this time we will contact all insurance companies and begin the application process. Some of them require a letter of interest (LOI) and others want you to submit a form on their website. Regardless of how they do it, we will take care of all of these steps. 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.

Weeks 6–9: Follow Up and Contracting

During this period we will continue to follow up and should begin to see your application making it through the payers credentialing process. Once your application has made it through the initial process, we will verify it transitions smoothly into the contracting phase. 

Weeks 10–16: Contract Negotiations and Effective Dates

This is when agreements start to come in and you will begin to see some results. Payer agreements are reviewed and submitted to you for your 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 45-60 days. We will then work through your payer list and check that we have effective dates and provider IDs for all applicable payers. We will work with you to provide this information to your billing company or department.

Seek Quality Credentialing Services

Physician Practice Specialists offers high-quality insurance credentialing services. The process can seem tedious and time-consuming, but our team of professionals works to simplify and streamline the process for our clients. We also provide medical practice consulting services, revenue cycle management consulting, and medical technology consulting. Contact us today to learn if our services are right for you.