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Medicare Credentialing Service | Provider Credentialing Service in USA
Credentialing refers to the procedure of confirming a healthcare provider's qualifications to ensure their capability of delivering healthcare services to patients. This process is mandatory for most health insurance firms, such as CMS/Medicare, Commercial plans, Medicaid, surgery centers, and hospitals.
The provider's credentialing process involves the validation of all their relevant documents to confirm that they are legitimate and up-to-date. These documents include their malpractice insurance, medical license, and DEA.
The following information is required to complete the credentialing process:
- Enhance your collection ratio
- Boost the likelihood of payment
- Augment your revenue stream
At CREDENSE, we offer comprehensive credentialing services to help you with the provider enrollment process and become an in-network provider, enabling you to receive reimbursements from various carriers. While medical credentialing services were once deemed "optional" for establishing a practice a few years back, today, it has become more crucial than ever for healthcare professionals to be in-network with insurance companies. You can count on CREDENSE to assist you in acquiring the appropriate credentials necessary to open a medical practice. Contact us today to learn more about our services.
Our credentialing team provides a thorough and knowledgeable service to help you become an in-network provider with the insurance carriers of your choice. We can also offer recommendations by analyzing your specialty and service area if you require guidance.
If you have gathered all the necessary documentation and are prepared to begin the provider enrollment process, please reach out to us. We cater to practices of all sizes, including solo practitioners, large practices with over 30 providers, and practices with only 1 or 2 providers. Our services encompass both individual and group enrollment for Medicaid, Medicare, and Commercial Payers.
Our team has an extensive knowledge base and expertise across multiple specialties and services, including DME.
- The medical provider credentialing process necessitates the participation of the healthcare provider, the organization, and the payer.
- Typically, the organization provides the healthcare professional with the necessary credentialing application(s), which may contain numerous pages. The provider is responsible for filling out the application, attaching all requested documentation such as board certification, college degrees, and more, and submitting it to the organization they intend to provide services.
- The organization then attaches additional documentation such as any claims history, background screen results, primary source verification, and more. After completing the healthcare facility portions of the application and attaching the appropriate documentation, they submit the finished application and supporting documentation to the payer.
- The payer reviews the application to assess whether the healthcare provider meets their standards, considering factors such as the provider's education (including program accreditation), residency or fellowship, recommendations, malpractice claims history, license, and more.
- This entire process is mandatory when the provider first joins a new practice and periodically thereafter, typically every two to three years depending on the payer.
What are the necessary details needed for credentialing?
The information required for credentialing may vary based on the payers, however, it is generally consistent and usually comprises of the following:
- Malpractice claims history, including suspensions and revocations
- License validation for practice, verified from the primary source
- National Provider Identifier (NPI) number
- DEA license
- License History
- Insurance details
- Employment history
- Academic qualifications, such as degrees and transcripts
- References from former employers or practitioners
- Board certification
American Medical Billing Agency | American Medical Response Billing | Denial Analysis in Medical Billing Services | Medicare Credentialing Service | Payment Posting in Medical Billing | RCM
Most Asked Medical Credentialing Questions, Answered
1. What should you expect from your Medical Credentialing Service Provider Company?
The process should begin with reviewing your specific network needs or an evaluation of the top payers in your area. Once final decisions are made, a contract is executed for the work to be done and payment is made. The Credentialing team gathers all necessary documents from the provider and contacts the insurance companies to begin the application process. For most companies, the process can be completed online through their portal for form completion. If not, they will be filled out and then sent via the required method. After submitting the applications, timely follow-up with the payers is crucial to ensure they were received. We give bi-weekly status updates to the client to keep them informed throughout the process until an effective date of enrollment is determined and a contract is received and executed, so the provider can begin claim submission.
2. When you outsource your Credentialing, what does that medical credentialing company provide you?
Outsourced Credentialing companies should respond to requests in a timely manner and provide excellent communication and complete transparency. A provider should work with a company that is professional and caring, taking ownership in the process as your representative in dealing with the insurance companies.
3. How does CREDENSE provide a complete physician credentialing service?
We assign them a Credentialing representative that they can communicate easily with and rely on. We offer to analyze their payers for their specialty and geographical location, as well as evaluate their contracts. We want providers to feel as though we are sitting in their office and are available when they need us.
4. How long does the provider credentialing process take?
The physician credentialing process generally takes between 90-120 days. We send a checklist of all documents that are required so that we can begin. Once they are received, we upload your data into our system and work to get your applications completed and submitted to insurance companies. We then follow up regularly with insurance companies to make sure that your credentialing applications are received and being processed and approved without unnecessary delays.
5. Do you have experience credentialing my specialty or for providers in my area?
Yes, we have credentialed for providers across the United States, including Hawaii, and for a variety of specialties and practice sizes!
6. Do you offer any service to keep up the documents and insurance contracts that expire and must be renewed?
Our Re-Credentialing and Maintenance package tracks expiration dates and renewals of contracts for your networks, such as BCBS, Aetna, and Cigna, as well as the various plans you are enrolled with under their umbrella, including Medicare and Medicaid re-validations. We also provide CAQH maintenance and attestation every 3 months, notifying the provider of expiring documents such as Malpractice, License, DEA, etc.