Physician payer credentialing, also referred to as provider enrollment, is the formal procedure for validating a healthcare provider’s eligibility to deliver patient care services. This essential process involves verifying the qualifications and background of healthcare professionals to ensure they adhere to the standards required for patient care. By obtaining credentialing approvals, healthcare providers demonstrate their compliance with the regulations set by insurance companies and hospitals, thereby facilitating their participation within in-network insurance networks. Ultimately, successful credentialing paves the way for reimbursement from insurance companies, making it a critical step for healthcare practitioners.
Information from Physician:
- Provider Name
- NPI (Type 1)
- Specialty
- SSN & DOB
- State Medical License
- DEA License
- Provider Birth Country & State
- CAQH User Name & Password
- NPPES/PECOS User Name & Password
- Malpractice insurance copy (PLI) policy
- Education and training certificates
- Practitioners updated CV
Information from practice:
- Practice registered Name & Business name
- Tax ID (EIN)
- Practice NPI (Type 2)
- Practice group Specialty
- Service/practice Location
- Mailing/Billing Address
- Practice Phone & FAX Number
- W9 form and IRS letter
- Malpractice insurance copy (PLI) policy
- Bank letter or Voided Bank check
- Practice manager name and contact info
Information from owners –
- Practice owners name
- Company incorporation document
- Ownership Percentage
- Owner DOB & SSN
- Owner Home address
- Owner contact details
- Group NPPES/PECOS Username & Password
- A business license (if applicable)
FAQs
Q.1 Are there any centralized databases or systems used for credentialing?
Yes, there are centralized databases and systems used for credentialing by insurance companies. Traditionally, providers had to individually go through a credentialing process with each insurance payer by submitting all the required documents. While this is still the case for some providers, the situation has evolved. Many insurance companies now utilize a centralized database to streamline the credentialing process. One prominent example is the Universal Provider Database (UPD), which is part of the online database operated by The Center for Affordable Quality Healthcare, Inc. (CAQH). The UPD serves as a central hub where providers can submit and store all the necessary information for credentialing. This database then collects and collates the information, making it readily available to insurance payers. Consequently, this centralized approach eliminates the need for providers to undergo the time-consuming and redundant process of individual credentialing with multiple payers.
Q.2 How long does the credentialing process usually take?
The credentialing process typically requires an extensive collection, submission, and verification of a comprehensive list of information. Due to the meticulous nature of this process, it is considered to be both time-consuming and lengthy. In general, the credentialing process often spans a period of approximately 2 to 4 months to complete. However, certain factors, such as incomplete documentation or administrative delays from the insurance provider’s end, may extend this timeframe to as long as 6 months. During these instances, the back-and-forth exchange of documentation may contribute to processing delays, further elongating the overall duration of the credentialing process.
What is the physician credentialing process checklist for adding healthcare providers at a newly established practice?
Physician payer credentialing, also known as provider enrollment, is a vital process that verifies the eligibility of healthcare providers to deliver patient care services. It involves thorough checks and approvals to ensure compliance with insurance companies and hospitals, allowing healthcare professionals to participate in insurance networks and receive reimbursement for their services.
To successfully navigate the physician credentialing process for adding healthcare providers to a newly established practice, there are several important steps and requirements to consider. These may vary depending on the healthcare facility, insurance plan, regulatory agency, and specialty. Here is a comprehensive overview of the key elements involved:
1. Medical Education and Training: Completion of an accredited medical school program is a fundamental requirement. Additionally, physicians must complete a residency program in their chosen specialty and obtain board certification or eligibility if applicable.
2. State Medical License: A valid and active medical license is essential for practicing medicine in the state(s) where the physician intends to operate. This typically involves passing state licensing exams and meeting specific requirements defined by each state.
3. DEA Registration: Physicians who prescribe controlled substances may need to obtain a Drug Enforcement Administration (DEA) registration.
4. National Provider Identifier (NPI): Acquiring an NPI number is crucial as it serves as a unique identifier for healthcare providers and is often required for billing and insurance purposes. Individual practitioners and group practices have different types of NPIs – type 1 for individuals and type 2 for group practices.
5. Malpractice Insurance or Professional Liability Insurance (PLI): Many healthcare facilities and insurance plans mandate physicians to have malpractice insurance coverage (PLI) to protect against potential liability claims.
6. Professional References: Providing references from colleagues, supervisors, or other healthcare professionals who can attest to the physician’s skills and ethical work practices.
7. Background Check: A background check report may be required to verify the physician’s criminal history if applicable.
8. Work History: Providing a detailed professional work history, including information about previous healthcare facilities and positions held.
9. Documentation: Preparing and submitting various documents, such as copies of medical licenses, diplomas, certifications, and more, as required by the credentialing entity.
10. Continuing Medical Education (CME): Documenting and demonstrating ongoing professional development through CME activities may be requested by some credentialing bodies.
11. Application Submission: Completing applications and submitting the credentialing application to the relevant healthcare insurance and network plans or regulatory agency to initiate the enrollment process.
12. Verification Process: The credentialing entity verifies all the information provided, which may involve contacting medical schools, residency programs, licensing boards, and references.
13. Credentialing Committee Review: After successful verification, the credentialing panel committee reviews the supporting documentation and makes a decision regarding credentialing approval, specifying an effective date to commence patient care or provide healthcare services.
It is important to note that the specific requirements and processes for physician credentialing can vary depending on the healthcare organization, insurance company, and state or region. To navigate this complex process efficiently, healthcare providers often seek assistance from credentialing specialists or services. These experts can provide valuable guidance and support throughout the credentialing enrollment journey, ensuring that all necessary requirements are met for successful participation in insurance networks.
Answers to sub-questions:
HOW TO UPDATE THE BILLING ADDRESS AND CREATE A W9 FORM?
To update the billing address, you will need to notify the relevant insurance companies and provide them with the new address information. Additionally, you may need to create a W9 form, which is a document used to provide your Taxpayer Identification Number (TIN) to insurance companies for tax reporting purposes. The form can be obtained from the Internal Revenue Service (IRS) website.
HOW TO IDENTIFY THE INSURANCE PAYERS FOR CREDENTIALING, INCLUDING STATUTORY REQUIREMENTS?
Identifying the insurance payers for credentialing involves determining the insurance companies you want to contract with for your practice. This should include all statutory requirements, such as Medicare, Worker’s Compensation, Tricare, and other commercial PPOs or HMOs. Research the insurance carriers and payers that align with your practice’s specialty and patient population.
HOW TO UPDATE THE ATTESTED CAQH PROFILE AND OBTAIN A CAQH ID?
To update the attested Council for Affordable Quality Healthcare (CAQH) profile, you can log in to your CAQH account and make the necessary updates to your information. This includes adding or modifying your qualifications, contact details, and practice affiliations. Each healthcare provider will have their own CAQH ID associated with their updated profile.
WHAT IS THE PROCESS FOR APPLYING FOR A GROUP NPI?
Applying for a Group National Provider Identifier (NPI) involves submitting an application to the National Plan and Provider Enumeration System (NPPES). You will need to provide information about your practice, such as the group name, address, and taxonomy code. This unique identifier is important for billing and insurance purposes.
HOW TO CREATE A NEW GROUP AND OBTAIN TAX ID DETAILS?
To create a new group, you will need to register your practice with the appropriate state authorities. This process involves providing details about your practice, such as the name, location, and type of entity. Once registered, you can obtain your Tax ID details from the IRS by downloading the e-file (CP-575) while collecting information on your Employer Identification Number (EIN).