Demystifying the Credentialing Process

Demystifying the Credentialing Process - Innet Credentialling

Credentialing is a confusing and often difficult process. Whether you choose to credential by yourself or with a specialist, there are three main phases that you will encounter as you try and get credentialed.

Application Aggregation

The very first phase of your credentialing journey starts with creating your application. There are a handful of forms, applications, and licenses you will have to track down to complete your application for each insurer. The first step you should take in this phase is assembling your personal licenses, hospital affiliations, malpractice information, and other documents about your qualifications, i.e. your specialties.

Most insurers will also ask that you fill out a CAQH, or Council for Affordable Quality Healthcare, application that helps with the verification of your documentation. This form is especially helpful if you are planning to credential with Medicaid. Each insurance is different in the elements they require for your application. While some ask for only the CAQH, others will ask for everything on your CAQH but not the actual form (confusing, we know!).

The key to surviving the application aggregation phase is to be organized. If you have documentation of all your licensing and official paperwork, this part shouldn’t be too stressful. Typically, aggregating your application can take anywhere from 5-30 days, depending on your organization. Be diligent and thorough during this phase to ensure you are giving the insurers everything they ask for in your first application.

Actual Credentialing

The second phase of credentialing begins with the submission of your application and accompanying forms. Once you have sent in your application, you may wait 60-180 days to hear back from each panel or company. The first step during the actual credentialing phase is verifying that your application has been received by the insurance panel—this alone takes roughly 30 days.

This part of the process requires a lot of proactive moves and follow-ups to make sure the insurance panel has received the proper paperwork, or if they’ve decided you need to add to your application. At least once a month you should be touching base with each insurance company to verify that your application is on track and progressing as quickly as possible. While you are checking up on your application, remember to ask if they have any requests or clarifications—additional information—for your application. This will ensure that your application is correct and ready to be accepted once it reaches its final credentialing steps.

The credentialing phase is the most hands-off portion of your credentialing process because your application is literally out of your hands and out of your control. Even though you have little control during this time, stay proactive by making phone calls and clarifications to keep the insurance companies moving at a timely pace.

Contract Creation

The last phase of credentialing revolves around contracting. Here you will finalize your contract with the insurance company and pay your fee as your process comes to a close. Contracting can take anywhere from 30-60 days; days full of paperwork and forms to complete and sign before your contracts are validated.

Credentialing is a lengthy and often complicated process, but it is necessary and beneficial for both you and your patients. As you compile your application, wait for credentialing, and sign your contracts, remember that even though time-consuming, credentialing is a worthwhile investment in your future.