Insurance credentialing is an essential process for receiving reimbursement for medical services billed by healthcare organizations and providers. There are several steps to this time-consuming process. In this blog, we’ll review insurance credentialing and the steps to getting credentialed with insurance companies.

What is Insurance Credentialing?

A healthcare provider is anyone who delivers medical services — physicians, nurse practitioners, physical therapists, dentists, etc. To receive reimbursement for services rendered during a patient’s visit, healthcare providers must complete the important insurance credentialing process.

The insurance credentialing process is when a healthcare organization registers a provider through specific insurance carriers or government payers. The primary goal is for the healthcare facility and provider to become “in-network” with the insurance company. After completing this process, the provider is affiliated with the specific insurance company and can request payment.

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8 Steps to Getting Credentialed with Insurance Companies

Again, there are several steps to the insurance credentialing process. This entire process typically takes 90 to 120 days. However, this depends on the insurance company and if the healthcare facility already has a contract established with said carrier. Here are the main insurance credentialing steps:

  1. Gather and Verify Provider Information: Before initiating the insurance credentialing process, healthcare organizations must first complete the provider credentialing process. This typically involves gathering and verifying the provider’s information and credentials. Some examples of required information include the provider’s education, work history, licenses, and references. If the provider doesn’t have a National Provider Identifier number, they should apply and obtain it as soon as possible. 
  2. Obtain Required Organizational Information – During the provider credentialing process, the employer should also gather additional organizational information required for insurance credentialing. Some of this information includes the employer’s tax identification number, practice locations, and billing procedures and policies. The organization should also obtain malpractice and liability insurance for the provider since all insurance companies require it.
  3. Complete a CAQH Application – After provider credentialing is complete, it’s time to begin the CAQH Provider Data Portal application. This portal houses the provider’s professional information in one central location and shares the information with those who request it. While this isn’t a mandatory step, most insurance companies require a CAQH account since it’s an easier way to access the provider’s and organization’s information. 
  4. Contact the Insurance Company – Typically, the healthcare company submits a letter of interest (LOI) to become an in-network provider with the insurance carrier. If the healthcare facility is already in-network, usually they will need to notify the insurance company of adding a new provider. If the facility isn’t in-network, then they will have to submit an LOI for the facility and provider.
  5. Submit Required Application and Documents – After the insurance company acknowledges the LOI, it will issue a reference or ticket number. The healthcare organization then submits any additional requested documents to start the contracting process.
  6. Complete Contact Negotiations – After submitting the application and required documents, the insurance carrier assigns a contracting representative to complete the contract negotiations. This part of the process is especially important because it specifies how much and when the healthcare organization and provider will receive reimbursement for medical services (i.e. fee schedule). Other contract negotiations may include stipulations, such as providing on-call and answering services or treating emergent conditions within a specific timeframe.
  7. Review and Sign the Payor Agreement – Next, the insurance company will send over a drafted contract for the healthcare organization to review. The healthcare organization then thoroughly reviews the contract. Some crucial details include coverage effective dates, fee schedules, and practice locations. After reviewing and verifying the contract for accuracy, the healthcare company signs the payer agreement and sends it back to the insurance carrier.
  8. Begin In-network Coverage – Once both parties have signed the completed contract, the healthcare organization should begin updating its billing services to include the insurance network. This may include claims forms, billing practices, and training employees on the new insurance billing requirements. However, the healthcare organization and provider may not begin billing for in-network services until the effective date of in-network coverage as outlined in the contract.  

Complete Insurance Credentialing Faster and Accurately

Insurance credentialing can be a long, difficult process. Streamline your healthcare organization’s insurance credentialing process with MedTrainer. Our all-in-one software offers comprehensive provider profiles, automated license verification and exclusions monitoring, and a proven enrollment workflow. If you’re looking to outsource your credentialing, consider MedTrainer Credentialing Services. Our regionally-based credentialing specialists can handle every aspect of your credentialing process from primary source verification to enrollment.

Learn more about MedTrainer Credentialing in this 3-minute video.