Credentialing checks a healthcare provider’s qualifications. Contracting establishes the terms for participating in an insurer’s network, including payment rates and billing requirements. Both matter, and credentialing approval alone does not make a provider in-network. Here is how the processes differ and connect.
What Is Insurance Credentialing?
Credentialing is the process of evaluating a healthcare provider’s professional qualifications against an insurer’s standards. Payers sometimes use enrollment or registration as broader labels, but credentialing and contracting remain distinct steps.
The main purpose of credentialing is to confirm that healthcare providers meet certain standards of quality and professionalism. During the insurance credentialing process, insurance companies typically require healthcare providers to submit a variety of documents and information. These often include proof of licensure and documentation of education, training, and certifications.
Other information requested during credentialing may include professional history, background checks, and evidence of compliance with applicable requirements. Insurers have different processes, and Physician Practice Specialists (PPS) helps providers organize their applications and respond to requests.
Once insurance credentialing is approved, contracting and enrollment requirements may still remain. Confirm the payer’s participation effective date before treating the provider as in-network. Credentialing approval does not guarantee reimbursement.
What Is Insurance Contracting?
Contracting is the process by which healthcare providers and insurers agree to the terms of network participation. These terms include payment rates, reimbursement policies, billing requirements, and other obligations. It is also called provider contracting or network contracting.
The goal of contracting is to reach an agreement that benefits both the healthcare provider and the insurance company. The contracting process is fundamentally a negotiation. Healthcare providers and insurance companies discuss terms for factors such as payment rates, reimbursement policies, and terms of service.
Contract terms vary by insurer, product, and provider type. A primary care physician, specialist, and hospital may have different terms. Review the covered products and services, payment rates, billing procedures, effective date, and termination provisions. PPS can help assess agreements and prepare a negotiating approach.
Navigating the Difference Between Credentialing and Contracting
Credentialing evaluates qualifications; contracting sets the business terms. The order and timing depend on the payer, so track both processes and confirm the effective date in writing. PPS supports credentialing and payer contract negotiations. Request a consultation to discuss the support your practice needs.
Sources: Aetna credentialing and contracting FAQs and Aetna participation process. Follow each payer’s own instructions and contract terms.