Get Credentialed & Enrolled With Premium Payer Networks

⦿ Provider credentialing is a process that healthcare organizations and insurance companies use to verify the qualifications and credentials of healthcare providers.
⦿ It involves reviewing the provider’s education, training, licensure, certifications, malpractice history, and other relevant information.
⦿ The goal of credentialing is to ensure that providers meet the quality standards of the organization or insurance company and that they are eligible to participate in their networks.

Credentialing is crucial for ensuring that healthcare providers meet the standards required by insurance payers or health plans. It establishes a contractual relationship between the provider and the payer, allowing for reimbursement of services.

⦿ Provider enrollment is the process of registering a provider with an insurance company or healthcare organization so that they can be reimbursed for providing services to patients.
⦿ It typically involves completing an application, providing documentation of the provider’s credentials, and signing a contract.

⦿ Application:
The provider completes an application providing information about their education, training, experience, licensure, and certifications.
⦿ Primary Source Verification (PSV):
The credentialing organization verifies the accuracy of the information provided by the provider by contacting primary sources such as medical schools, residency programs, licensing boards, and professional organizations.
⦿ Review and Decision:
The credentialing organization reviews the provider’s application and PSV results and makes a decision about whether to grant the provider privileges to practice within their organization or network.
⦿ Enrollment:
If the provider is approved for credentialing, they will then need to enroll with the insurance company or healthcare organization.
⦿ Contract:
The provider will sign a contract outlining the terms of their participation in the network.

Re-credentialing typically occurs every two to three years, but this can vary. Staying aware of re-credentialing deadlines and proactively engaging in the process ensures continued eligibility within the payer’s network.

⦿ The credentialing and enrollment process can take anywhere from 90 to 180 days, or even longer in some cases.
⦿ The length of time can vary depending on the complexity of the provider’s credentials, the efficiency of the credentialing organization, and the requirements of the insurance company or healthcare organization.

It’s essential to check with the specific payer, but in many cases, providers may be able to offer services while the credentialing process is underway. However, reimbursement may be contingent on successful completion of the process.

⦿ Incomplete or inaccurate applications
⦿ Delays in obtaining PSV results
⦿ Missing or expired documentation
⦿ Changes in provider status (e.g., new licensure, changes in employment)
⦿ Lack of communication between providers and credentialing organizations

CRMB’s expert team handles the entire credentialing process, from tracking deadlines to completing necessary tasks such as primary source verification and background screening. We work closely with providers and payers to expedite approvals and smooth the enrollment process.

⦿ Complete all applications thoroughly and accurately.
⦿ Respond promptly to requests for information.
⦿ Keep all documentation up-to-date.
⦿ Communicate any changes in provider status to credentialing organizations promptly.
⦿ Consider using a credentialing management service to help streamline the process.