Insurance Credentialing Process Overview
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.