If you plan to treat Medicare or Medicaid patients, you must clear every CMS credentialing requirement first. Skip a step and you risk landing on the dreaded “red list,” which means zero reimbursement. Relax, though: credentialing is not rocket science. Think of it as brewing your morning coffee—simple, but you still need the right steps.

In this guide, you will learn about:

• Provider enrollment basics (PECOS, CMS-855I, CMS-855B)
• Medicare and Medicaid credentialing checklists
• Telemedicine credentialing rules for virtual visits
• Delegated credentialing and how large groups speed things up

As a medical billing specialist, I have helped thousands of clinics move from pending to paid status without a single denial. You can do the same. Follow along and see how to:

• Build a spotless CAQH profile
• Avoid common credentialing denials
• Keep your NPI linked to the correct taxonomy code
• Meet every re-credentialing deadline

Have questions like “How do I join Medicare as a new provider?” or “What is the fastest way to update PECOS?” They are answered here. By the end, you will know exactly what CMS expects, which forms to file, and how to stay on the green list so your healthcare claims get paid in full and on time.

CMS Credentialing Requirements for Healthcare Providers in the USA

CMS (Centers for Medicare & Medicaid Services) credentialing requirements refer to the processes and standards that healthcare providers must meet in order to be approved for participation in Medicare and Medicaid programs. 

Some of the basic requirements are:

1). Obtain Your National Provider Identifier (NPI)

The initial step in the CMS credentialing process is obtaining your NPI number. It is a 10-digit identifier utilized for all healthcare billing, including payment for Medicare and Medicaid. You will not be able to send in or get reimbursed for any claims if you do not have it.

Application for your NPI is possible through the National Plan and Provider Enumeration System (NPPES). The application involves basic information such as your name, practice address, tax ID, contact information, license, and credentials.

The majority of healthcare professionals register for the NPI first, since they will also require it during later PECOS registration and CMS enrollment.

Having an NPI is among the most usual prerequisites for any medical billing operation. It ensures that CMS and payers are able to track who is offering the services, particularly for specialties such as family medicine, behavioral health, or physical therapy.

2). Ensure Your License is Current and Validated

You will need a current and unrestricted license to practice in the state in which you will be treating patients. CMS will not accept an expired or restricted license, and they will check for this information when you are enrolling.

Depending on your provider type, you may also be asked to furnish proof of board certification or further training. For instance, some positions, such as cardiologists or nurse anesthetists, will require additional credentials.

The CMS also cross-checks the Office of Inspector General (OIG) List of Exclusions. In case you have participated in healthcare fraud, abuse, or other disqualifying conduct, you will be excluded from participation in Medicare. This is done to make sure that nothing but eligible health care providers are permitted to charge Medicare and Medicaid.

3). Fill out the CMS Enrollment Forms or Use PECOS

Once your licensure and NPI are verified, the following step is to formally enroll in Medicare. You may do this by filing the respective CMS-855 form or by enrolling online through PECOS, or Provider Enrollment, Chain, and Ownership System.

Every form has a particular function:

• Individual healthcare providers, such as physicians, therapists, and nurses, use CMS-855I.
• The CMS-855B is utilized for group practices and clinics.
• CMS-855A is for institutional providers, including hospitals and nursing facilities.
• CMS-855R is for reassigning Medicare benefits to an entity, such as a group or an organization.

PECOS is the most popular choice among providers as it enables quicker submission and immediate tracking of application status. Filing the incorrect form or omission of documentation will hold up your credentialing process by a great deal, hence you need to do this step with care.

4). Credentialing by a Medicare Administrative Contractor (MAC)

During CMS enrollment, every provider passes through a Medicare Administrative Contractor for review. A MAC is a private firm that manages Medicare enrollment, handles claims processing, and verifies provider credentials within its region.

A MAC checks your forms, confirms your license, and makes sure every supporting document is in place. If something is missing, you receive a request for more information instead of a flat denial. Processing times vary by region, so keep local timelines in mind.

When the MAC approves your file, CMS issues a Provider Transaction Access Number (PTAN). You will need this PTAN whenever you submit Medicare claims or update your record in PECOS.

Smooth MAC credentialing sets the stage for trouble-free billing with Medicare beneficiaries.

5). Medicare Participation Agreement

After credentialing, CMS asks you to sign a Medicare Participation Agreement. This short contract spells out what you agree to when you treat Medicare patients.

• You follow all CMS regulations, including coding rules, reimbursement limits, and fraud-prevention policies.
• You accept the Medicare fee schedule as full payment, except for allowed coinsurance or deductibles.
• You send clean claims on time and bill only for medically necessary services.
• You maintain quality-of-care standards, which CMS may audit through its quality reporting programs.

Once the agreement is on file, you can begin seeing Medicare patients and submitting electronic claims without delay.

6). Ongoing Compliance with Federal and State Rules

CMS approval is not the finish line. Providers must stay current with both federal regulations and state requirements to keep billing privileges active.

➜ Federal rules

• Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• HIPAA privacy and security safeguards
• Policies in the Affordable Care Act that affect provider enrollment
• Current CMS billing and coding guidelines

These standards apply to physicians, therapists, hospitals, home health agencies, and every other Medicare-enrolled entity.

➜ State rules

• Professional licensure laws require an active, unrestricted license in each state where you practice.
• Scope-of-practice statutes limit which services your license allows you to perform.
• Each state Medicaid program has its own enrollment steps that build on federal guidance.
• Managed Care Organizations (MCOs) may add extra credentialing checks before they will contract with you.
• State privacy laws, such as California’s CCPA, can be stricter than HIPAA.
• If you deliver telehealth, you must follow every state’s telemedicine and cross-state licensure rules.

Meeting these federal and state obligations helps you avoid claim denials, overpayment recoupments, and potential exclusion from government programs.

7). Clear Background Check

CMS only accepts providers whose records are clean. During both initial credentialing and the three-year recredentialing cycle, CMS runs a background check that looks at professional qualifications, criminal history, and any past Medicare fraud or abuse. Failing this review can delay or deny enrollment, revoke billing privileges, and trigger legal or financial penalties.

What CMS reviews:

• Criminal convictions at the federal or state level
• Medicare and Medicaid exclusion lists
• License status plus any disciplinary actions
• Malpractice claims and settlements
• Education, training, and residency verification

8). Malpractice Insurance Requirements

Every provider must carry active malpractice (professional liability) insurance to protect patients and themselves against errors or negligence claims. CMS checks coverage at enrollment, at recredentialing, and during random audits.

• Most plans require at least one million dollars per claim and three million dollars aggregate each year, although limits can vary by state or specialty
• A current Certificate of Insurance (COI) must list the insured name, policy number, coverage dates, limits, and carrier
• Providers changing jobs or retiring may need tail coverage to insure prior acts

Without proof of adequate coverage, CMS can deny enrollment or terminate participation.

9). Meeting CMS Quality Standards

CMS expects all enrolled professionals and facilities to deliver safe, effective, and high-quality care. Compliance is also tied to value-based payment models.

Key quality checkpoints:

• Adhering to Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• Reporting through MIPS if eligible
• Tracking and submitting Clinical Quality Measures (CQMs)
• Failure to meet these benchmarks can reduce reimbursement or trigger corrective action plans.

10). Provider-Specific Rules

CMS tailors requirements to the provider’s role.

• Pharmacists, physician assistants, and other non-physician practitioners may need proof of specialty certification or documented supervision
• Telemedicine professionals must hold a valid license in each state where patients are located and meet state-specific virtual-care rules

11). Additional Certifications CMS May Require

Depending on services offered, you might need extra credentials alongside standard Medicare enrollment.

12). Site Visits and Operational Standards

CMS may conduct on-site inspections during initial enrollment, revalidation, or whenever red flags arise. Inspectors confirm that:

• The office address on your application physically exists and matches signage
• Posted hours are accurate and staff are present
• Patient-care areas, record storage, and equipment meet health and safety rules
• Policies align with HIPAA, infection control standards, and local building codes

Passing the site visit proves that your practice is real, operational, and ready to serve Medicare and Medicaid beneficiaries.

CMS Telemedicine Credentialing Requirements

Telemedicine follows the same core CMS enrollment rules as in-person care, yet it adds a few extra layers that reflect the unique, screen-to-screen setting. Providers who plan to deliver virtual visits to Medicare or Medicaid patients must meet each standard below to secure reimbursement and avoid claim denials.

Here are the key CMS telemedicine credentialing requirements:

Provider Enrollment

• Complete the correct CMS-855 application and choose the telemedicine service type when prompted.
• Submit your National Provider Identifier (NPI), proof of active license, malpractice coverage, and any state-specific forms.
• Keep your information current in PECOS so payers can verify your status before processing remote-care claims.

Licensure Across State Lines

• Hold an active license in the state where the patient sits during the visit, even if you live elsewhere.
• Many providers rely on the Interstate Medical Licensure Compact or similar nursing and psychology compacts to speed up multi-state approval.
• Track renewal dates carefully; an expired out-of-state license can halt payment for every virtual visit.

HIPAA-Compliant Technology

• Use a HIPAA-compliant telemedicine platform for video, chat, and file sharing.
• Encrypt data in transit and at rest, maintain audit logs, and restrict user access to the minimum necessary.
• Provide patients with the standard Notice of Privacy Practices that explains how their data is stored and shared.

State and Federal Telemedicine Rules

• Follow your state’s practice standards, prescribing limits, and modality restrictions for virtual care.
• Some states enforce payment parity laws that require commercial plans to cover telehealth at the same rate as face-to-face visits; CMS often mirrors these rules for Medicaid.
• Document each visit just as thoroughly as an in-office encounter, including location of patient and provider.

Patient Consent

• Obtain informed telehealth consent before the first virtual session of the patient.
• Explain how the service works, any technology risks, and steps taken to secure data.
• Keep a signed or electronically acknowledged consent form on file, as CMS may request it during audits.

Supervision and Delegation

• If nurse practitioners, physician assistants, or other clinicians deliver remote care, meet CMS and state supervision or collaboration requirements.
• Clearly outline who can provide which services, how oversight is documented, and how escalation to a supervising physician occurs.

CMS Delegated Credentialing Requirements

Sometimes a health plan or large provider group lets a separate entity handle day-to-day credentialing. This is known as delegated credentialing and it comes with its own set of CMS rules. Even when the work is handed off, the original organization is still responsible for meeting every CMS standard.

Here are the key CMS delegated credentialing requirements:

Formal Delegation Agreement

A clear, written agreement must be in place before any work starts. The document should

• list every task the delegate will complete, such as primary-source verification or final credentialing decisions
• spell out performance targets and how results will be reported
• describe how the delegating organization will monitor, audit, and if needed, cancel the arrangement
• require the delegate to follow NCQA or an equivalent set of credentialing standards when the health plan is NCQA-accredited

Oversight and Accountability

The health plan—or other delegating group—keeps full responsibility for compliance. To show CMS that proper oversight exists, the plan must

• review and approve the delegate’s policies and procedures before work begins
• audit the delegate, usually once a year, to confirm rules are being followed
• maintain written records of every review, audit, and corrective action
• step in quickly if audits reveal non-compliance

Credentialing Standards to Maintain

The delegate has to apply all routine credentialing checks, including primary-source verification of

• active state license and any required specialty license
• DEA certificate if the provider prescribes controlled substances
• board certification when the specialty calls for it
• education, training, and recent work history
• current malpractice insurance with adequate limits
• sanctions, disciplinary actions, and the OIG exclusion list

These safeguards ensure every provider in the network is licensed, competent, and in good standing.

Revoking or Correcting Delegation

If audits show that credentialing standards are not met, the health plan must

• issue a corrective action plan with clear deadlines
• revoke the delegation if problems persist
• resume direct credentialing in-house or choose a new, compliant delegate

By keeping a close eye on every delegated activity, the health plan protects patients and stays aligned with all CMS credentialing regulations.

FAQs

What is CMS credentialing and why does it matter?

CMS credentialing is the process that confirms a provider’s identity, professional qualifications, and compliance record before allowing Medicare or Medicaid billing. Without it, claims will be rejected and you cannot treat covered patients.

Which core documents do I need to start a CMS application?

You will need an active state license, National Provider Identifier (NPI), malpractice insurance certificate, work history, education and training records, and a completed CMS-855 application (or the PECOS online equivalent).

How long does initial credentialing for CMS usually take?

Most clean applications pass through a Medicare Administrative Contractor in thirty to ninety days. Missing paperwork, pending license renewals, or background issues can extend the timeline.

How often must I complete CMS recredentialing or revalidation?

CMS requires recredentialing every three years for all enrolled providers. A separate revalidation notice can arrive sooner if you move, change ownership, or trigger other risk factors.

What is the difference between a CMS-855 paper form and PECOS?

CMS-855 is the paper enrollment packet. PECOS is the secure online portal that lets you fill out the same information electronically, upload documents, and track your application status. Use one method per enrollment cycle.

Can my practice delegate CMS credentialing to a Credentialing Verification Organization (CVO)?

Yes. A formal delegation agreement must spell out the CVO’s duties, performance standards, audit schedule, and termination clauses. Even with delegation, your organization remains accountable for meeting every CMS rule.

Does CMS perform site visits and why?

Yes. CMS or its contractor can conduct a site visit during initial enrollment, revalidation, or when they detect billing anomalies. Inspectors verify that the listed address exists, hours are posted, staff are present, and records are secure.

Do I need a separate state license for each location where patients are treated, including telehealth?

Yes. You must hold an active license in every state where the patient is located at the time of service. This applies to both in-person care and telemedicine appointments.

Imagine you’re running a healthcare practice, and a new physician joins your team. They’re experienced, talented, and eager to start helping patients.

However, there’s a hiccup—they haven’t been credentialed yet. Now, the clock’s ticking, and you’ve got patients to see.

What do you do? Do you hit pause until the credentialing process is complete, or is there a way to move forward?

It’s a scenario many healthcare providers face, and while it may seem like a sticky situation, it’s not all doom and gloom.

There are some ways to navigate these waters, and it’s essential to understand the dos and don’ts to keep things running smoothly.

Credentialing is a big deal. It’s how medical professionals get recognized and reimbursed by insurance companies like Medicare.

Essentially, the stamp of approval says, “Yes, this provider meets the necessary standards to offer services safely and effectively.”

Without it, patient safety and the integrity of the healthcare system could be at risk.

But here’s the kicker:

What happens if that new physician isn’t credentialed yet, and you need to see patients anyway?

It is a very critical situation, but the truth is, there are temporary solutions that can keep your practice moving forward.

Let’s see when and how a physician can see patients without being credentialed.

What Does It Mean to Be Credentialed?

Credentialing is the process where healthcare providers, like doctors, nurses, or specialists, are verified for their qualifications.

This process involves reviewing a provider’s education, training, licensing, malpractice history, and work experience to ensure they meet the standards of the healthcare institution and are eligible for insurance reimbursements.

While credentialing is typically a standard process for doctors, nurses, and other healthcare professionals, sometimes there is a delay between when a provider joins a new facility or health plan and when their credentialing is officially completed.

If a physician isn’t credentialed, they can’t officially bill insurance companies, including big players like Medicare.

Without that credentialing stamp of approval, they’re not recognized as a valid provider under those insurance contracts.

This can lead to a few complications:

First, you won’t be reimbursed for the services provided, and second, it could even raise concerns about compliance and patient safety, depending on the situation.

Without credentialing, health plans, including Medicare, Medicaid, or private insurers, don’t recognize a provider.

This means that:

• The provider cannot bill for services rendered.
• Patients might face out-of-pocket expenses if they choose to see a non-credentialed provider.
• Insurance companies won’t reimburse for services rendered by the non-credentialed provider.

Can Non-Credentialed Providers See Patients: Potential Risks

YES, in certain circumstances, non-credentialed providers can see patients—but it’s not as simple as just letting them dive in.

There are significant restrictions and potential risks involved that you need to consider before allowing any provider to treat patients without full credentialing.

Everything runs on high standards, strict protocols, and paperwork in healthcare.

Why?

Because patient well-being, legal obligations, and the financial health of a healthcare organization all depend on it.

Credentialing plays a considerable role in this system. It ensures that a provider meets specific qualifications and standards to safely treat patients and be authorized to bill insurance companies, including large payors like Medicare and private insurers.

But what happens when a provider isn’t credentialed yet and still sees patients?

Well, here’s where things get tricky.

Allowing a non-credentialed provider to see patients before completing the credentialing process can open the door to several risks that could harm your practice financially and legally.

Let’s take a closer look at these risks:

1). Reimbursement Denial

One of the most significant risks of seeing patients before completing the credentialing process is the potential for reimbursement denial.

Insurance companies, including major payers like Medicare and private insurance providers, have strict rules regarding credentialing.

They typically require that healthcare providers are officially credentialed and authorized before any services are eligible for reimbursement.

Insurers require that healthcare providers meet specific qualifications and have the necessary approvals before they are eligible for reimbursement.

Without proper credentialing, any services provided will likely be denied payment.

If a provider has seen patients without credentialing approval, they cannot collect payment for the services rendered until their application is processed.

This could lead to significant financial challenges for the practice, especially if the provider has seen many patients.

2). Out-of-Pocket Costs for Patients

Patients typically rely on their insurance coverage to help pay for medical services.

If a provider is not credentialed with the patient’s insurance, patients may be required to pay out-of-pocket for the services they receive.

This can create several problems for both the patient and the provider.

Insurance companies generally won’t reimburse for services rendered by non-credentialed providers.

As a result, patients will likely be responsible for the full cost of their care, which they may not have budgeted for.

Most patients expect their medical expenses to be covered by their insurance.

When faced with unexpected costs because their provider isn’t credentialed, it can lead to frustration, dissatisfaction, and even a loss of trust in the provider.

This can result in a negative impact on patient retention and the provider’s reputation.

3). Compliance and Liability Issues

Seeing patients without the necessary payer credentialing poses a significant legal risk, including compliance and liability issues.

Providers who fail to adhere to proper credentialing protocols may face legal challenges, especially if something goes wrong during care provision.

If a non-credentialed provider is involved in a malpractice case or any legal issue, they may find themselves without legal protection or coverage under their malpractice insurance.

This could leave the provider personally liable for the financial and legal consequences.

Healthcare organizations must comply with various regulations, including credentialing-related ones.

Providing services without completing the credentialing process could be seen as a violation of these regulations.

Failure to comply with credentialing requirements could sometimes lead to fines, sanctions, or even the termination of a provider’s license.

Physicians who see patients before their credentialing is complete take on considerable legal and financial risks. Malpractice claims, insurance issues, and violations of healthcare regulations could jeopardize their practice and professional standing.

When Can a Non-Credentialed Provider See Patients? Key Scenarios Explained

While proper credentialing is a cornerstone of healthcare compliance and reimbursement, there are specific circumstances where providers can legally see patients before their credentialing process is complete.

These exceptions provide necessary flexibility in the healthcare system while maintaining patient safety standards.

We’ve outlined the key scenarios below where providers may be permitted to practice prior to full credentialing approval:

Temporary Credentialing or “Provisional” Status

Sometimes, a provider may be granted temporary or provisional credentialing to see patients while the complete credentialing process is underway.

This is commonly seen when a physician joins a hospital or practice and needs to start seeing patients immediately, even if their full background check isn’t completed yet.

From an insurance perspective, provisional status can lead to service reimbursement, but it’s not guaranteed.

For example, Medicare might reimburse for the care a temporarily credentialed physician provides, but this arrangement is typically short-term and subject to various conditions.

Supervision by a Credentialed Provider

A non-credentialed provider may be able to see patients if they are working under the supervision of a credentialed provider.

This is common for non-physician providers, such as nurse practitioners (NPs) or physician assistants (PAs), who work under a supervising physician.

Let’s say a Nurse Practitioner is in the process of being credentialed by Medicare but has already started working at a primary care clinic.

While the nurse waits for her credentials, she may see patients if her supervising physician is present or available to oversee her care decisions.

When it comes to insurance, Medicare and other insurers typically reimburse the credentialed supervising provider for services rendered.

This means that while the supervising physician can bill for the care provided, the non-credentialed NP won’t be reimbursed directly.

The supervision arrangement ensures that the supervising physician remains legally responsible for the care provided and that billing is tied to the supervising physician’s credentials.

Emergency or Unforeseen Circumstances

There are situations in which emergency care or urgent needs arise, and a non-credentialed provider may be the only one available to treat patients.

In these cases, insurance companies like Medicare has specific emergency services and coverage guidelines.

For example, a doctor is not yet credentialed with Medicare but works in an urgent care facility.

One day, an unexpected influx of patients requires her to step in and see a patient with a complex condition.

While they are not credentialed, the facility calls her in due to the emergency, and she provides care.

For emergencies, Medicare and most other insurers will generally cover care provided by a non-credentialed provider.

This is because patient health and safety are prioritized in emergencies, and credentialing delays are recognized as an administrative issue.

Out-of-Network Providers

In some instances, a non-credentialed provider may not be in-network for an insurance plan, but patients may still be able to see them as out-of-network providers.

The patient would typically be responsible for a higher out-of-pocket cost, but the insurance may offer partial reimbursement.

For instance, a specialist who isn’t credentialed with a specific insurance company.

However, he agrees to see a patient who has that insurance.

The patient might still be able to get some reimbursement from their insurance provider, but it will likely be at a reduced rate, and they may need to pay higher co-pays or deductibles.

Medicare, for example, has a network of approved providers, but it does not allow patients to see out-of-network doctors.

However, if the provider is non-credentialed, reimbursement will likely be limited or unavailable, and patients might have to pay the full cost.

Telemedicine and Cross-State Licensing

With the rise of telemedicine, non-credentialed providers might also encounter questions related to cross-state licensing or telehealth provisions.

A physician who isn’t credentialed in a particular state may still offer services via telemedicine to patients in that state.

For example, a licensed physician in Texas hasn’t yet been credentialed by an insurance provider in Louisiana.

However, she offers telemedicine consultations to patients in Louisiana, raising the question of whether Medicare will reimburse those services.

Many insurance companies, including Medicare, are adapting to the rise of telemedicine.

Reimbursement policies are evolving, but if a provider is often licensed in the state where the patient is located, they may still be able to offer telehealth services, even if they are not yet credentialed with the insurance provider.

But, don’t worry!

We’re here to help you every step of the way and make it super easy.

First things first, let’s talk numbers. The Centers for Medicare & Medicaid Services (CMS) reports that 76 million people are now enrolled in Medicaid. That’s a huge jump from May 2021, which had almost 75,888,651 enrollees! Many Americans depend on Medicaid for their healthcare, so it’s important for providers like you to be properly credentialed to help this growing group.

In this blog, we’ll explain the Medicaid credentialing process step by step. We’ll talk about why this is important, what mistakes to watch out for, and provide you with a simple, step-by-step guide to get your credentials fast and in line with the rules.

By the end, you’ll know everything you need to start accepting Medicaid patients confidently.

What is Medicaid Credentialing in Healthcare?

Medicaid credentialing is when healthcare providers show their qualifications, experience, and skills so they can serve Medicaid beneficiaries. By meeting Medicaid’s high standards, providers uphold the quality of healthcare services offered. Providers need the following for Medicaid credentialing:

• Send in proof of your education, like transcripts and residency certificates.
• Summarize your work history, including previous jobs and clinical experience, to show that you are reliable and capable.
• Make sure you hold a valid state medical license.
• Obtain board certification in their specialty area, like the American Board of Family Medicine for family practitioners.
• If you prescribe controlled substances, make sure to share your Drug Enforcement Administration Number (DEA).
• Show continuous malpractice insurance coverage for patient and provider protection.
• Offer references from colleagues, supervisors, or mentors to vouch for their qualifications and professionalism.

Types of Medicaid Credentialing

Each type of credentialing has a specific purpose. It ensures that healthcare providers are qualified and capable of delivering quality care to Medicaid beneficiaries. We’ve put together a list of different types of Medicaid credentialing to help you understand better:

Initial Credentialing

This is for anyone who is just starting out or joining a new network. Before you can treat Medicaid patients, you’ll need to meet their initial credentialing requirements. Basically, you’ll need to submit things like your medical school transcripts, licenses, certifications, and board credentials. Once you get that Medicaid number, you’re good to go!

Re-credentialing

This is like a checkup for your credentials. Every 3 to 5 years, Medicaid checks to see if you still meet their standards and keep your qualifications current. Make sure to renew your licenses and certifications, and prove that you’ve been staying current with your continuing medical education (CME) credits. They will check your performance reviews and patient satisfaction surveys to ensure you are providing quality care.

Provisional Credentialing

This is the “let’s get you started” option. If you need to see Medicaid patients quickly, you can get provisional credentialing while your full application is being processed. It’s a temporary approval based on an initial review of your qualifications. During this time, they’ll keep a closer eye on you to make sure you’re following Medicaid’s standards. Once your full credentialing is complete, you’ll get that permanent Medicaid provider number, and you’re officially part of the program.

Step-by-Step Guide to Getting Credentialed with Medicaid

Now that we’ve talked about the different types of Medicaid credentialing, let’s dive into the entire Medicaid credentialing process. Understanding the step-by-step process to credential with Medicaid is important. This guide helps you understand the specific requirements, documents, and timelines for caring for Medicaid patients.

Step #1: Understand Your State’s Medicaid Requirements

The first step to getting credentialed with Medicaid is to understand your state’s specific requirements. While Medicaid programs have some commonalities across states, each one manages their own processes and eligibility criteria.

To get started, you’ll want to gather:

• Copies of your current, valid professional licenses and certifications
• Proof of your up-to-date liability insurance coverage
• Your National Provider Identifier (NPI) and Tax ID numbers
• Details about your practice – specialty, services offered, location, patient demographics, etc.
• Some states require additional items like background checks or fingerprinting. Contact your state Medicaid office to confirm their full list of requirements.

Having all of these items ready will make the application process smoother. Reach out to our credentialing specialists if you need help understanding your state’s specific Medicaid credentialing rules and documents. We’re here to help you prepare a complete application from the start.

What are the Requirements for Out-of-State (OOS) Medicaid Provider Enrollment?

If you’re a provider from another state wanting to enroll in Medicaid, here’s what you need to know:

➜ You have to meet the same federal screening standards as Medicare. This includes background checks, credentialing, and everything like that.

➜ Some states are easygoing and don’t ask for extra screenings if you’ve already been screened by a different state. But some might still require you to go through the same steps as in-state providers.

➜ You can get paid back for emergency services you give to Medicaid beneficiaries. This makes sure patients receive care on time, even if they’re away from their home state.

➜ If you have Medicaid’s prior approval, you can also get paid back for non-emergency services. This covers treatments and procedures that have already been approved.

➜ If some medical equipment or devices aren’t available in the patient’s home state, you can sign up to offer these important services.

Step #2: Get Your National Provider Identifier (NPI)

The NPI is a unique 10-digit number for identifying healthcare providers. You’ll need it to apply for and bill Medicaid.

If you don’t have an NPI yet, simply go to the NPPES website and apply online. The application is straightforward – just provide some basic personal and professional details.

If you’re in a group practice, make sure your group has its own NPI number too. Each provider and the group itself needs a distinct NPI.

Once you have your NPI, keep your information current on the NPPES website. Update anything that changes – your practice location, contact info, credentials, etc. Accurate details ensure smooth billing and communication with Medicaid.

The NPI application process is quick and easy. Just set aside a few minutes to get this essential ID number. Then you’ll be ready to move forward with Medicaid provider enrollment.

Step #3: Complete and Submit the Medicaid Provider Enrollment Form

After obtaining your NPI, it’s time to fill out the Medicaid provider enrollment application for your state. This crucial step registers you as a Medicaid provider.

1. First, go to your state’s Medicaid website and download the provider enrollment form. For example, here is New York State’s form.
2. Next, carefully complete the entire application. Provide your personal and practice details like name, address, contact information, professional credentials, services offered, and more.
3. Also include important billing details like your Tax ID Number (TIN).

Double check that all information is accurate before submitting the form.

Step #4: Complete Background Checks and Fingerprinting

Most states require Medicaid providers to undergo background checks and fingerprinting. This ensures you have no criminal history that could risk patient safety.

To complete this step:

• Run background checks on yourself to verify your history. Disclose any past issues upfront.
• Get fingerprinted. This allows the state to cross-check your identity against criminal databases.
• Comply with all background check requirements mandated by your state. Different states have different rules. But full compliance is key.
• Be patient. Background checks can take time to process. Stay in touch with the state to move it along.
• Disclose everything. Trying to hide past problems will only delay or derail your application. Honesty and transparency are vital.

The background check process protects patients. Embrace it as an important part of credentialing. Complete this step fully and correctly. That gets you one step closer to serving Medicaid members.

Step #5: Get Ready for Review and Inspection

Once you submit your Medicaid application, the state Medicaid office will take a close look at your application and documents. They may also conduct an on-site inspection of your practice.

Take this time to get ready and collect any extra information the Medicaid office might need to help process your application easily. If asked, be ready to give more documents.

The inspection will verify that your facilities, operations, and patient records meet state regulations. Inspectors might visit your office, check compliance procedures, and look over patient files.

This step makes sure your practice follows Medicaid care standards. This is your chance to show that you have the staff, equipment, and procedures to provide quality healthcare services to Medicaid patients. Approach it as an opportunity to showcase your readiness. Dealing with any possible problems ahead of time will make acceptance easier.

Step #6: Get Your Medicaid Provider Number

After your Medicaid application gets the green light, you’ll get your own Medicaid Provider Number (MPN). This ID number is important for filing claims and getting paid for treating Medicaid patients.

Once you’re approved, you’ll get an email or a letter letting you know that you’ve been credentialed. With this notice, you’ll receive your new MPN.

➜ If you have an MPN, you can begin billing Medicaid and get paid back for your services. This is the last step to become an authorized Medicaid provider.

➜ If your application is delayed, make sure to check in with the Medicaid office quickly. Keeping track of the process can help fix problems and speed up approval.

➜ Approval times can change depending on the state, but they usually take about 30 to 60 days after you submit a complete application.

Now that you have your MPN, you can start treating Medicaid beneficiaries and getting paid back. This milestone shows that your hard work to get credentialed has really paid off. Just remember, you need to keep your information up to date to keep your Medicaid billing privileges active.

What is the Medicaid Provider Number (MPN)?

The Medicaid Provider Number (MPN) is a unique six-digit identifier assigned to healthcare providers participating in the Medicaid program. The first two digits represent the state where the provider operates, and the last four digits indicate the type of facility. For instance, California hospitals have MPNs that begin with “05” followed by four additional digits specific to the hospital.

The MPN may also be referred to by other names, such as the OSCAR Number (Online Survey, Certification, and Reporting), Medicaid Identification Number, or simply Provider Number. These terms are interchangeable and all refer to the same unique number used to identify Medicaid providers.

Step #7: Start Serving Medicaid Patients

Now that you have your Medicaid provider number, you can start offering healthcare services to Medicaid recipients. Here are some key things to keep in mind:

• Make sure to update your provider profile in the Medicaid directory. Include your correct contact info, service hours, and the services you offer. This makes it easy for patients to find you.
• Teach your staff about Medicaid policies, including how to check eligibility, handle billing, and ensure compliance. When everyone is on the same page, things run smoothly.
• Find out how to use your state’s Medicaid Management Information System (MMIS) to submit claims and check patient eligibility. Accurate training eliminates Medicaid billing problems.
• Before you provide services, make sure to check the patient’s current Medicaid eligibility using the state verification system. This keeps you safe from denied claims.
• Make sure to provide great care and keep an eye on how happy patients are. Improving things all the time makes the care experience better for Medicaid patients.

Just follow these steps, and you’ll be on track to serve the Medicaid population successfully while staying compliant and getting the best reimbursement.

The Significance of Medicaid Credentialing for Healthcare Providers

Getting Medicaid credentialing is a smart choice for healthcare providers who want to grow their services and reach a large market. As a Medicaid-approved provider, you can offer your expertise to a large segment of the population that relies on this government healthcare program for their medical needs.

Here are the main benefits of getting credentialed with Medicaid:

Expand Your Reach and Help More Patients by Accepting Medicaid

As a healthcare provider, joining Medicaid lets you truly help patients who need it most. Lots of people on Medicaid have a hard time finding doctors who take their insurance. By accepting Medicaid, you open your practice to a wider population in need of care. You can fill more appointment slots, run at full capacity, and reach out to serve patients from different areas and backgrounds. It means more patients can get the essential healthcare they need. Taking Medicaid can help your practice and support your goal of giving great care to all patients, no matter what kind of insurance they have.

A Steady Stream of Reimbursement Through Medicaid Credentialing

As a healthcare provider, it’s important to have a reliable source of payment to keep your practice financially healthy. Getting credentialed with Medicaid helps you get paid for the services you offer to Medicaid beneficiaries. This includes payment for office visits, hospital care, procedures, and other services. Medicaid reimbursement gives you a steady income, so you can concentrate on providing quality care without stressing about money issues. Medicaid provides a reliable way to get paid for taking care of your patients. Credentialing helps you access this important reimbursement support for your practice.

Gain Access to Valuable Training Resources

Getting credentialed with Medicaid gives you access to many helpful resources for professional development that can enhance your practice. Medicaid has training programs, webinars, and other chances for you to improve your skills and provide better care.

For example, the Centers for Medicare & Medicaid Services (CMS) provides free online training modules and educational webinars to keep you up-to-date on the latest regulations, quality initiatives, and best practices. Using these Medicaid resources can help you easily access the tools and knowledge you need to improve your operations, try new care models, and get better results for your patients.

Build a Trusted Reputation through Medicaid Credentialing

When healthcare providers get credentialed with Medicaid, they show they are serious about meeting high-quality standards. Medicaid checks licenses, certifications, and backgrounds carefully. So, if you’re credentialed, it means you’ve passed their tough checks. This builds a reputation in the community as a trusted and reliable provider who is dedicated to delivering quality care. Patients can feel sure about picking a provider who is approved by Medicaid. A good reputation will bring in more patients looking for a provider they can trust. Getting credentialed with Medicaid shows that you meet high standards and boosts your professional reputation.

Gain Access to a Massive Patient Base

Medicaid lets healthcare providers reach and support underserved communities. Accepting Medicaid helps you connect with patients such as low-income families, pregnant women, children, and people with disabilities. You can really help those who need it the most. Taking care of these overlooked groups helps close the gap in healthcare and boosts the wellbeing of the community. This is your chance to make a bigger difference and achieve your goal of helping others. Helping more people and giving good medical care to those who really need it is possible with Medicaid credentialing.

Avoid Legal Troubles and Hefty Fines by Staying Compliant

As a Medicaid provider, it’s important to keep up with all the Medicaid rules and requirements. Having the right credentials makes sure you meet the standards for documentation, billing, and services. This keeps you safe from big fines, penalties, and legal issues later on. For instance, adhering to Affordable Care Act and Medicaid guidelines for services and documentation allows you to accurately submit claims and get paid for your work. Keeping up with credentialing helps you feel confident that your practice is running in an ethical and legal way.

How to Avoid Medicaid Credentialing Mistakes?

Credentialing mistakes can badly impact your healthcare practice revenue and your ability to provide care to Medicaid beneficiaries. Here are some key points that show how to avoid common credentialing mistakes with the Medicaid program.

Always Stay Updated with Medicaid Credentialing Policies

Staying up to date with Medicaid credentialing policies is super crucial for healthcare providers to avoid costly mistakes. Otherwise, if you don’t follow the latest requirements, you might get your claims denied, lose your credentials, and even get kicked out of Medicaid programs.

Honestly, it’s simple to miss small changes in application processes, document standards, and eligibility rules. Medicaid policies change from state to state and keep evolving all the time. And if you miss an update, it could put your credentials and claims reimbursement in danger.

So, make sure to check your state’s Medicaid website often and sign up for email alerts. Oh, and don’t forget to bookmark the credentialing section and check out any new announcements. This little habit helps you stay updated on changes that affect providers.

By the way, tools like CAQH ProView are great for keeping track of compliance. The automated system keeps an eye on your credentials, license renewals, and expiration dates. Honestly, it’s such an easy way to stay on top of important deadlines you really need to meet.

Never Skip the Double-Check

Forgetting to double-check your Medicaid credentialing data can be a really costly mistake. Seriously, it can cause big problems for healthcare providers. Even just a small mistake or missing document can lead to rejected applications and long delays in getting approved. And until the issues are sorted out, you won’t be able to see Medicaid patients or get paid for the services you provide.

You see, you need to submit a lot of detailed information and documents for the credentialing process. It’s so easy to make a typo, skip a field, or forget a needed document when you’re handling a ton of paperwork. But, these small mistakes can totally slow everything down.

That’s exactly why it’s super important to check every piece of information carefully before you submit your credentialing application. Double-check spellings, dates, license numbers, certifications—you name it! Better yet, getting a colleague or a professional credentialing service like BellMedEx to look over your documents can help catch mistakes you might have missed.

In the end, if you put in a bit of extra effort at the start, you can avoid a big headache later. Plus, you’ll make sure you don’t miss out on Medicaid money while waiting to resubmit and get approved. So please, don’t let a simple mistake mess up your credentialing. Just double-check your data!

Maintain Transparency in the Credentialing Process

Be honest about your work history, qualifications or any disciplinary actions for a smooth credentialing process. If there have been gaps in employment history or any other issue, openly disclose these upfronts. Providing context and complete explanations can prevent any kind of misunderstanding and build trust with credentialing entities. Being truthful helps you to avoid any rejection or delays due to an error in your credentialing application.

Make Regular Communication with the Medicaid Credentialing Team 

Effective and open communication with Medicaid entities can speed up the resolution with your credentialing process. You need to identify the right assistant in the Medicaid office who can help you to get timely updates and responses to all of your queries.

After submission of your application, it’s important to check the status regularly. If the Medicaid office requests additional information, respond immediately. Always open lines of communication to address any issue at the spot and keep the credentialing process moving forward.

Additional Tips for Successful Medicaid Credentialing

• Think about using credentialing management software or bringing in credentialing experts to make the application process smoother. These tools and professionals help automate tasks, track progress, and make sure all necessary documents are correct and submitted on time.
• Consider joining groups like the American Medical Association (AMA) or the National Association of Community Health Centers (NACHC). These groups offer important resources, guidance, and support to help you get through the Medicaid credentialing process.
• Do regular checks to make sure your practice follows Medicaid rules. These reviews keep records accurate and current, and they help spot potential issues before they turn into problems.
• Get to know the Medicaid appeals process just in case your credentialing application gets denied. It’s important to know the steps you need to take, the documents you have to gather, and the key deadlines to make your reapplication successful.

Therapist insurance reimbursement is essential for timely payment, but it only happens if you meet all the requirements and regulations set by the insurance companies.

First, you should know that insurance payers only pay those healthcare providers who are credentialed with them and only for the care services provided to in-network patients having coverage benefits of that specific care service.

It is also essential for you to check whether the insurance company covers the patient’s therapy expenses because many insurers do not offer insurance coverage for mental health services.

Furthermore, getting paid is easy, but getting instant reimbursement depends on your network of insurance providers. Some insurance companies process insurance claims for therapists and pay healthcare providers instantly, while some take time. So, it would help if you always researched when credentialing with any insurance provider. However, it is on your end to submit insurance claims with no error to speed up the mental health claims process, get reimbursed without any delay, and avoid claim rejection or denials.

To avoid errors, you should familiarize yourself with the therapy billing codes and therapist fee schedules that are essential for proper billing.

Additionally, knowing the insurance provider reimbursement rates will help you understand how much you should expect for each service.

You also need to be aware of the copayments for therapy sessions as they are typically part of the overall insurance payment for therapy services.

It’s important to understand insurance authorization for therapy, especially if you are submitting claims for therapy services. If you are working out-of-network, payment may be slower, and the rates might differ from in-network therapy reimbursement. Make sure you have clear insurance provider contracts for therapists to ensure accurate and fair compensation for your services.

Finally, understanding therapist payment policies and engaging in insurance negotiation for therapists will help ensure that your services are compensated fairly. Always review the EOB (Explanation of Benefits) for therapists to understand how your claims are processed and what adjustments may need to be made for payment.

How Do Therapists Get Reimbursed by Insurers?

After providing therapy services to patients, therapists are either paid by patients or insurance providers, and sometimes by both. To get paid by insurance providers, you must be part of a particular insurance panel. Each insurance company facilitates therapists with various insurance panels. Some of the top insurance panels for therapists are Blue Cross Blue Shield (BCBS), Aetna, Cigna, and Medicare. The process of joining a panel is referred to as credentialing or paneling.

After getting on any of the insurance panels, you are now eligible to receive payments from insurance providers for the services you provide to covered patients. In simple words, a covered patient comes to see you for therapy services: you provide care services, prepare a bill, and submit an insurance claim for therapists to their health insurer, and the insurer reimburses you.

Getting on the panel is compulsory to get paid by insurance providers. But, being credentialed with insurers also brings some drawbacks. Here, we discuss both the benefits and disadvantages of paneling with insurers.

Benefits of Joining an Insurance Panel for Therapists

Benefits of becoming part of insurance panels include:

Referrals

As a therapist, you can get referrals from your insurance providers after getting on a panel with them. This can help you grow your practice while caring for more therapy patients and receiving insurance payment for therapy services.

Wider Reach

Getting on a panel enables you to access many patients who might need help to afford therapy care expenses if they were receiving it as out-of-network therapy payment. Being part of insurance panels allows you to receive timely reimbursement from insurance providers for services rendered.

Reputation

Being in-network with an insurance panel helps you grow your reputation as a reliable and trustworthy therapist, and also helps ensure that insurance reimbursement is more consistent and predictable.

Drawbacks of Joining an Insurance Panel for Therapists

According to the California Health Report, 42% of therapists don’t accept insurance. Here are the reasons why:

Delays

The therapist credentialing process may take two to four months. During that duration, a therapist may not be able to provide therapy services to covered patients and thus may experience delays in receiving insurance reimbursement.

Administrative Duties

Insurance providers have various billing requirements. Claim filing may take a little more time for you to fulfill all their conditions. Additionally, opting for automated software or an insurance clearing house may add extra costs for processing insurance claims. Therefore, many therapists only accept insured patients to ensure payment for their services is consistent and timely.

Now, the next step is to get credentialed with insurance providers to get reimbursed by them. Here are some valuable tips for you to get on panels with insurance providers.

How to Choose an Insurance Provider as a Therapist in the USA?

There are many insurance providers.

Each has different reimbursement rates as per therapy session or per visit, as well as other requirements, restrictions, and guidelines for billing and payment.

It would help if you chose the most suitable providers whose rates are closer to your charge amount and who willingly accept providers at their panels. Asking your peer therapists can help you make the perfect decision when choosing an insurance provider. Inquire them about their experiences while working with an insurer you will be credentialed with.

Here are some factors to consider when you’re checking out different providers.

➜ Faster Payments, Reliability, and Reimbursement Rates

Before joining the panel of any insurance provider, consider the following:

• How quickly do they typically pay a therapist after a claim is submitted?
• How reliable are they? Do you know of any therapists facing difficulties when getting reimbursed by this particular provider?
• What reimbursement rates do they offer? Are the rates close to your charges, and higher than those of other providers?

These factors can positively influence your decision when joining an insurance panel.

➜ Marketing and Referral Services

Choose insurance panels that can help market your therapy services or provide additional marketing support. Also, look for those that offer referrals.

➜ Accessibility and Support

Join panels with insurance providers who are easily accessible and offer support when you need to discuss something.

➜ Gather All the Information

Before joining any therapist insurance panel, gather the following information to streamline the credentialing process:

• Your license information
• Your NPI number
• A copy of your resume
• Professional liability insurance
• Paperwork for any advanced training you have received
• Complete CAQH application

➜ Follow Up

After submitting your application, contact the insurance provider to ensure they have received everything. Some providers may require a specific processing time. However, you should follow up after three or four weeks.

How Do You Bill and Get Paid by Insurance Providers?

Once you become part of an insurance network, you can submit bills and receive reimbursement for the services you provide to patients covered by that provider. However, you must learn how to bill insurers for healthcare services rendered. Many therapists prefer outsourcing the claims submission process to third-party medical billing companies, but you can also handle it yourself, though it may be time-consuming and challenging.

You can manually submit a claim via email using the CMS-1500 form, a standard claim form for medical and mental health services.

Alternatively, insurance providers often allow you to submit claims through their online portal. When using the online portal, you follow the prompts on the screen, and the system automatically fills out the CMS-1500 form for you.

Before completing the CMS-1500 form, gather the following patient information:

• Patient’s full name
• Date of birth and SSN (if required)
• Policyholder ID
• The main insured person on the plan (if the client is a dependent)
• Date and place services were provided (in-office or online)
• ICD-10 codes
• Service code and modifier for each service provided
• Your NPI
• Your practice’s tax ID
• Your practice’s NPI (if different from your own)
• Your practice’s address

Claims can sometimes be rejected, denied, or clawed back by insurance providers due to errors. Claims are rejected when a mistake is detected before processing. They are denied when the insurance provider processes the claim and refuses reimbursement due to major issues, such as duplicate billing, invalid medical necessity, or patient ineligibility.

Occasionally, insurance providers reimburse therapists but later determine that the payment was invalid and ask the therapist to return the funds, a process known as a claim “clawback“.

Therefore, always double-check bills for errors and omissions before submission, as even a minor mistake can delay your reimbursement. Make sure the claim is completely error-free.

Finally, submit the claim either online or by mailing the CMS-1500 form. By following these steps, you can easily bill and get reimbursed by insurance providers.

Conclusion

For therapists, getting reimbursed by insurance providers is relatively easy if claims are submitted promptly, without errors, and in accordance with payer requirements and HIPAA regulations. However, it can become more complicated, as it often requires specific skills and expertise that an in-house team may lack. Therefore, outsourcing to a third-party medical billing company can be a game-changer, helping therapists receive timely payments from insurance providers.

In this comprehensive guide, we will discuss the best insurance panels for therapists, the pros and cons of getting on the panel, and understand the key factors involved in choosing an insurance panel which can be proved the best for therapists.

Insurance Panels for Therapists

An insurance panel for therapists is a group of therapists credentialed with an insurance company to provide healthcare services to patients in a network with that insurer. Joining an insurance panel requires a comprehensive process known as the credentialing process. The therapists must provide their qualifications before joining an insurance panel.

After joining a panel, therapists have access to a vast pool of patients who need therapy services. However, it can be challenging for therapists to get on panels, as they accept only those who can offer unique benefits to insurance company policyholders.

For example, insurance companies might be interested in onboarding therapists who:

• Provide care services on an in-demand schedule, including outside standard business hours
• Offer therapy services at competitive hourly rates
• Hold credentials as specialists in specific areas of therapy
• Have completed relevant education and training courses
• Support patients with less common diagnoses

Furthermore, therapists can apply to work with multiple insurance panels, whether state or nationwide companies. It is suggested that therapists look for the best insurance panels before applying to any panel. However, the process of getting on panels may take a few months or longer in some cases. Here, we provide them with easy steps to get on an insurance panel.

The Best Insurance Panels for Therapists in the USA

Here, we’ve compiled a list of top insurance panels for healthcare providers. Each offers unique features and benefits, though what qualifies as “best” may vary by provider needs. This list aims to give therapists valuable insights into which panel may align best with their practice goals:

• Blue Cross Blue Shield (BCBS) ➜ Best for therapists seeking broad patient reach and high provider participation.
• UnitedHealthcare ➜ Best for therapists who value easy access to digital tools and high reimbursement rates.
• Aetna ➜ Best for therapists looking for resourceful provider support.
• Cigna ➜ Best for therapists who need simple credentialing and efficient claims.
• Medicaid and Medicare ➜ Best for therapists aiming to serve low-income and elderly patients.

1). Blue Cross Blue Shield

Blue Cross Blue Shield (BCBS) is known for providing comprehensive healthcare coverage to individuals and facilitating healthcare providers with high reimbursement rates for the services provided to patients in-network with BCBS. The main aim of the insurance company is to offer a personalized approach to health care. Their members live and work in different communities in various states of the US. For this purpose, they work with different healthcare providers to serve their policyholders with quality and affordable healthcare.

Blue Cross Blue Shield comprises 33 independent companies operating nationwide, providing healthcare coverage to 115 million members in all 50 states of the USA. In addition, 1.7 million doctors and hospitals are in contract with BCBS insurance companies, the highest number of paneled healthcare providers among other insurance companies.

Furthermore, it is advantageous for therapists in the US to get on a panel with BCBS as the insurance company has diverse application requirements in each state. For example, the insurance panel in Illinois uses the CAQH application for the credentialing process. In other states, the process of credentialing new therapists may be different. Similarly, the reimbursement rates also vary by location, specialty, and therapists’ qualifications.

2). UnitedHealthcare

UnitedHealthcare is a perfect choice for qualified therapists. The insurance company provides care services to a wide range of patients nationwide. It can help therapists get more patient appointments and increase the flow of their practices. UnitedHealthcare is on the list of the best insurance panels for therapists because it facilitates healthcare providers with instant payment and high reimbursement rates.

In addition, UnitedHealthcare allows healthcare providers, i.e., therapists, to become part of its insurance network easily. They have to follow these simple steps:

1. Apply with relevant information and essential documents
2. The panel will verify your experience and right to provide care services
3. After that, they will review and sign your participation agreement

After joining their network, as a therapist, you can access a wide range of patients and become part of their insurance panels. They have onboarded 1.3 million healthcare professionals and 67,000 hospitals and care facilities across the US. They also facilitate their participants with a UnitedHealthcare Provider Portal and several digital tools where healthcare professionals can manage eligibility and referral activity.

UnitedHealthcare opens doors of opportunity for therapists as it has a large pool of patients with different coverage benefits. The insurance company provides health benefits plans to patients of all ages across the United States. Patients can have coverage benefits for individuals and families, health insurance through work, and Medicare and Medicaid benefits.

3). Aetna

Aetna marks itself on the list of best insurance panels recognized for its commitment to providing support for therapists. The insurance company provides different healthcare plans that benefit patients and allow participant providers to reach them.

The insurance panel enables its in-network providers to find the tools and resources they need to stay informed and focus on caring for their patients. Becoming part of Aetna also provides healthcare professionals with resources to get paid faster while managing documents, claims, and reimbursements.

4). Cigna

Cigna welcomes therapists on its insurance panel, offering them a range of plans. The insurance panel is known for its supportive role for providers, facilitating them with easy credentialing, high reimbursement rates, hurdle-free claim processing, and fast reimbursement. Cigna Insurance Panel requires very little from the therapists to get credentialed. A few of the requirements are:

• CAQH Application
• Signed agreement to participate
• Signed and completed standard or state-mandated application
• State medical license
• Professional liability coverage
• Admitting privileges, if applicable
• Education and training, including board certification, if applicable
• History of employment

Furthermore, Cigna also provides therapists with digital tools to help them verify patient eligibility and benefits, check claims, payments, and fee schedules, and increase efficiency while providing healthcare services.

5). Medicaid And Medicare

Medicaid and Medicare are US government healthcare programs offering care services to low-income individuals, elderly individuals, and individuals with specific disabilities.

Medicare programs provide healthcare benefits to individuals who are above 65 years of age or suffering from particular disabilities, while Medicaid facilitates low-income individuals with healthcare benefits.

Both programs accept therapists in their network, but they usually pay less as they are government programs than private insurance panels.

However, these programs are on the list of the most secure, reliable, and best insurance panels, as sometimes they can pay high reimbursement rates for CPT codes for therapy sessions performed in various locations.

Comparison of Best Insurance Panels for Therapists in the USA

How to Choose the Best Insurance Panels?

Before choosing any insurance panel, we suggest therapists to consider a few points. It will help them choose the best insurance panel that benefits their practice. These points include but are not limited to only those mentioned here.

If you are a therapist looking for a perfect insurance panel, consider these key factors before getting on board. Many panels might accept your credentialing application, but the one with certain features could be the best fit for your practice.

➜ Popularity of Panel in Your Area

It will take some time to search thoroughly for the most popular insurance panel, but as a result, you can find the best from the pool of panels in your area. Also, search for panels that patients in that area mostly use. Discussing with your fellow therapists who are already part of insurance panels can give you insights into the popularity of insurers. Their experience with various panels lets you know about the pros and cons of a particular insurance panel. Remember! Look for something other than popular ones.

Here are some other factors to consider.

➜ Panel Stability and Reliability

Before choosing an insurance panel, check for stability and reliability. You can do this by checking its history and reputation in the industry and getting feedback from other healthcare providers in-network with that panel.

➜ Panel Requirements

Each panel requires the therapists to fulfill certain conditions to get approval for credentialing. You should look for the one that matches exactly your clinic’s goals and capacity.

For example, some insurance panels may want therapists to work a certain number of hours or provide services to a certain number of patients.

So, carefully read about their terms and know about the number of patients and working hours. If their conditions align with your practice, then go for it; otherwise, search for a better one.

➜ Reimbursement Rates

Each insurance provider (Medicare, Medicaid, private insurers) has its own fixed reimbursement rates, usually less than that of patients who pay out of pocket. Government plans, such as Medicare and Medicaid, even pay less. As a therapist, you should be part of insurance panels that reimburse you at rates closer to the rates you charge for healthcare services provided to out-of-network patients.

For example, three patients, A, B, and C, visit your clinic for therapy sessions. They are in a network with different insurance panels, AAA, BBB, and CCC. You provide the same therapy services to all of them. The AAA’s allowed amount for the care service is $50, the BBB’s is $60, and the CCC allows $45 for the same care service. Now, getting on a panel with the BBB can be the best choice as it can reimburse you $60 for the services you provide, which is a higher rate than the others.

➜ Panel Size

Checking for insurance panel size is also one of the critical factors to consider before choosing a panel. Large insurance companies have more slots in their panels for healthcare providers, offering higher reimbursement rates but high competition. In contrast, you may have less competition if you become part of small insurance panels. If you live in a rural area where therapists are in demand, you should go for small insurance panels.

Moreover, joining large insurance panels can help you grow your practice, as there might be a high number of patients in-network with those large insurance companies.

How to Get on Insurance Panels?

The process of getting paneled is also known as getting credentialed. It is a time-consuming process, but following these simple steps can assist you in getting enrolled with top payers in your region:

Find and Select an Insurance Panel

First, search and select an insurance panel(s) easily aligned with your healthcare practice goals. Use all your potential resources to get the best insurance options. Asking your colleagues or finding information through online sources will assist you in learning more about a particular panel.

Gather Documents

After choosing an insurance company, it is time to gather all the required information and documents. Each insurance panel requires its own set of eligibility criteria, including licensure type, years of experience, and certifications or specializations. Before applying, ensure that you have all the necessary documents, i.e., a resume, professional license, proof of liability insurance, and any relevant certifications. This will play an important role in streamlining the credentialing process.

Complete The CAQH

Insurance panels have their own application process, but you must complete the CAQH (Council for Affordable Quality Healthcare). Insurance providers usually prefer using CAQH for credentialing. To get on the panel, you must fill out a CAQH application, after which you will get a CAQH number from insurance providers. You can apply it to multiple panels using it. Through this form, insurance companies can verify your data.

CAQH allows you to apply in two ways: print or fill it out online. It is better to fill out the form online, as there are fewer chances of making errors. Before submitting the form, check it twice, as slight errors can slow down the credentialing process.

Submit an Application

Your application is now ready to be submitted. It is recommended that you keep a copy of every document you attach to your credentialing application.

Follow Up

Don’t be a sleeping rabbit after applying to get on insurance panels. Keep following up on your application, as insurance companies receive many applications. Contact the concerned persons regularly once you receive notification that your application has been processed.

Knowing whether your application is accepted may take 2 to 4 months. The insurance companies will inform you if anything needs to be added to your application. Contacting them enables you to fulfill requirements before any unpleasant response. Be prepared for any of the responses. If it is rejected, you can appeal for resubmission, but it may take another few months. Therefore, follow-up is necessary to act on time.

Review the Contract

At the final stage, before accepting, you must review the contract after getting approval from insurance companies to get on their panels.  Review and negotiate terms such as reimbursement rates, company requirements from you, etc. Be sure that all the arrangements in the contract are beneficial for you and meet your practice goals.

Conclusion

In summary, picking the right insurance panel can greatly help therapists who want to grow their practice and claim reimbursements easier. Each of these main insurance companies—Blue Cross Blue Shield, UnitedHealthcare, Aetna, Cigna, and government programs like Medicaid and Medicare—has special benefits.

BCBS has a large network, UnitedHealthcare offers easy-to-use tools for providers, and Cigna has a simple process for credentialing. These options help therapists find patients, make administrative work easier, and improve their earnings.

Finding a panel that matches your goals can really help you create a successful and lasting practice, even though “best” can mean different things to different people.

Get Credentialed with Your Preferred Insurance Panels

We know getting credentialed can be a total pain, but we’ve got your back. Just tell us which payer networks you want in on, and we’ll have you credentialed and ready to roll in no time.

Get Credentialed Now

---

Assisting with credentialing and enrollment, BellMedEx has been consistently reliable from the first day of our relationship.

Dr. Mike

Internal Specialist Medicine

Top Features

✓ Provider Credentialing
✓ Payer Enrollment Service
✓ Hospital & Clinical Privileges

How long does it take to get credentialed with insurance companies and why?

The average time it takes for providers to get credentialed is between 90 to 120 days (and up to 180 days in some cases). Some insurance companies process applications faster, while others may take longer, especially for certain specialties.

So, the time frame varies significantly, depending on tons of factors. We’ll talk about them in detail as you scroll through.

The Timeline for Provider Credentialing Process

The credentialing process for healthcare providers with insurance companies involves several key steps, each taking a specific amount of time.

Here’s a detailed timeline breakdown of the credentialing process.

1. Preparing Documentation (1-2 Weeks)

The initial step involves collecting all necessary documents that may take 1-2 weeks. A credentialing specialist can review these documents thoroughly who also conducts primary source verification to ensure accuracy.

Providers should prepare a checklist to streamline this phase.

Application: General information including personal details, contact information, and professional background.

Education: Documentation of education such as diplomas, specialty certificates, and additional qualifications.

Licenses and Certifications: Copies of current and valid medical licenses, board certifications, and registrations.

Work History: Detailed account of previous positions, dates of employment, and responsibilities.

Malpractice Insurance: Proof of malpractice or liability insurance coverage.

References: Professional references from colleagues, supervisors, or mentors.

DEA Registration: Drug Enforcement Administration registration details for prescribing controlled substances.

Personal Identification: Valid identification documents like a driver’s license, passport, or social security number.

Background Check: Verification of criminal records and/or disciplinary actions.

Credential Evaluation: Assessment against the organization’s specific criteria.

Preparing and gathering necessary documentation helps streamline the credentialing process and avoid delays.

2. Submitting Applications (1-2 Weeks)

After gathering documents, providers fill out application forms for getting credentialed with insurance companies. This step includes gathering personal details, filling in required information, reviewing for accuracy, and submitting the applications. Generally, it takes 1-2 weeks, but using robust credentialing software speeds up the process.

• Get personal, professional, and supporting documents (1-2 Days).
• Fill out the application forms and start leveraging software (3-5 Days).
• Proofread and review the entire application once again (1-2 Days).
• Submit the application with methods specified by insurance companies (1-2 Days).
• Track submissions, respond to requests, and follow up with the insurance companies (ongoing).

Using the right tools and strategies helps you manage, complete and submit applications effectively within the 1-2 week timeframe.

3. Primary Source Verification (4-6 Weeks)

During this crucial phase, insurance companies verify credentials directly with educational institutions, licensing boards, and previous employers. This credentialing step ensures the accuracy and authenticity of the provider’s qualifications.

The time frame can vary depending on the responsiveness of the institutions and agencies involved. But generally, it takes around 4-6 weeks. You can do nothing about it, just make sure you give accurate information and truthful documentation.

4. Insurance Company Review (4-8 Weeks)

Once verification is complete, the insurance company reviews the application in detail. This includes checking compliance with their internal standards. The time frame is usually 4-8 weeks but can vary based on the thoroughness of their review process.

The insurance company reviews the application, assessing the provider’s qualifications, experience, and background. The process may include:

• Application Assessment
• Compliance Check
• Background Verification
• Internal Review Timelines

Delays can occur if the insurance company needs further clarification or if there are issues with the documentation provided. It can also take long if the insurance company’s internal review committees meet less frequently.

5. Board or Committee Approval (1-2 Weeks)

The application is then presented to a credentialing committee or board, which meets monthly or bi-monthly. It evaluates all findings and makes a decision on the provider’s credentialing status.

The timing of the next available meeting can influence how quickly the application is reviewed. But usually, this step in the provider credentialing process takes 1 to 2 weeks approximately. You cannot do anything to expedite the process.

The credentialing committee typically includes healthcare professionals and administrative staff, and it reviews the application in detail. They assess qualifications, experience, and findings from the background checks and compliance reviews.

After the committee review, the members raise concerns and talk about the provider’s suitability for inclusion in the network. And then, they vote on whether to approve, deny the application, or request some more information.

If approved, you’re done with the initial credentialing process and get in-network with the insurance. But if the additional information is required, the process gets extended until the next committee meeting.

6. Contracting and Enrollment (2-4 Weeks)

After approval, you as a healthcare provider will receive and review a contract outlining participation terms. You can negotiate before signing. Once signed, you are officially enrolled in the insurance network.

The insurance company updates their systems to include you as a new provider in their network. This ensures that patients and other stakeholders can see that the provider is now part of the network. The provider receives a notification confirming their enrollment.

This step in credentialing typically takes 2-4 weeks to complete, depending on the efficiency of both the provider and the insurance company.

In total, the entire credentialing process can take between 12 to 24 weeks (approximately 3 to 6 months), depending on these factors:

• The completeness of the application.
• The responsiveness of third-party verification sources.
• And internal processing times of the insurance company.

But why does the credentialing take ages? Let us answer that!

Why Does Provider Credentialing Take So Long?

As a healthcare provider, you’ve jumped through all the hoops – submitting your application, paying fees, providing documents – to get credentialed. But instead of the few weeks you expected, it’s been months, and your insurance credentialing status is still stuck in limbo. What gives?

You’re not the problem. The snail’s pace is by design on the insurers’ part.

Insurance companies follow a lengthy, rigorous credentialing process to vet every provider before allowing them to join their network. This involves verifying your qualifications, work history, malpractice coverage, and other aspects that affect your ability to deliver safe, quality care. They must comb through primary source verifications, license checks, and other certifications.

So while frustrating for providers, the long credentialing timeframe stems from the insurer’s due diligence. For you, it means playing the waiting game.

Here’s an overview of what contributes to these delays.

Extensive Verification

Credentialing requires thorough verification of a provider’s education, training, licenses, certifications, work history, and malpractice records. This process involves contacting multiple institutions, which can take time.

Primary Source Verification

Each piece of information must be confirmed directly with original sources, such as medical schools, licensing boards, and other institutions. This step ensures accuracy but lengthens the timeline of provider credentialing.

Background Checks

Comprehensive background checks, including criminal history and malpractice verification, are crucial for patient safety. These checks can take considerable time to complete, making sense of prolonged credentialing timeframe.

Committee Reviews

Credentialing committees need to review and approve applications. Delays can occur if there are scheduling conflicts or backlogs of applications in the review process.

Incomplete Applications

Missing or incorrect information in a provider’s application can cause significant delays. Requests for additional documentation or corrections can add weeks or even months.

Lack of Standardization

Different healthcare facilities may have varying requirements and processes for credentialing. There’s no standardization and this creates redundancy and inefficiencies, prolonging the process.

High Volume of Providers

When many providers are seeking credentialing at the same time, backlogs can develop, slowing down the overall process.

Response Times from Institutions

Delays can occur if educational institutions or previous employers take too long to respond to verification requests. A slow response can add weeks to the provider credentialing timeline.

Discrepancies in Documentation

Additional follow-ups are required if there are discrepancies in the information provided. Investigating these issues can significantly extend the credentialing process.

Scheduling Conflicts

If the credentialing board has a busy schedule, it may take longer to get applications reviewed and approved.

Internal Processing Delays

The insurance company or healthcare facility may have internal processing delays due to staffing, policy changes, or procedural bottlenecks.

Tips to Speed Up Insurance Credentialing Process

To expedite the credentialing process, providers must start the process earlier, use robust software, establish a clear workflow, set reminders for follow-up, and hire a good healthcare credentialing company.

Streamline Documentation

To speed up the insurance credentialing process, healthcare providers can follow these steps to improve how they handle and submit their application documents:

➜ Organize Your Documents: Create a list of all the documents you need, like insurance information, licenses, and certificates. Put them in a special folder so you can get to them easily.

➜ Use Standard forms: Submit documents in widely accepted formats (like PDF). This reduces confusion and makes it easier for insurance companies to review your materials.

➜ Double-Check Everything: Make sure all of your documents are complete and accurate before sending them in. Delays can happen when information is missing or wrong.

➜ Digital Submission: Whenever possible, submit applications and documents electronically. This speeds up the process and reduces the risk of lost paperwork.

➜ Follow Up: Once you’ve sent your documents to the insurance company, call them again to make sure they got them and to find out what’s going on with your application.

Conduct Pre-Credentialing Reviews

Conducting pre-credentialing reviews is an effective way to speed up the credentialing process. By taking proactive steps, you can ensure that everything is in order before submitting applications.

➜ Use Pre-Screening Checklists:

• Develop checklists that list all the necessary documents and information needed for credentialing.
• Check these lists to identify any missing items or potential issues before you submit the application.

➜ Hold Mock Credentialing Sessions:

• Conduct practice sessions that simulate the credentialing process.
• Use these sessions to spot any bottlenecks or problems that might slow down the process.

Engage a Credentialing Service

As a healthcare worker, you can get outside help to speed things up if you need to.

Using third-party companies that offer credentialing services is one strategy. These businesses already have systems in place and connections with payers that make the credentialing process go faster. As part of their routine work, they fill out forms, check papers, and follow up with insurance companies. Because of this, you will be able to focus more on each patient.

Working together with a Managed Service Organization (MSO) is another choice. MSOs offer full credentialing support as one of their many services. Some of the things they do to help you get accepted are talking to payers, filing claims, negotiating contracts, and managing the medical revenue cycle. This all-around service makes sure that your credentials are always up-to-date and that you get paid quickly for your claims.

Strengthen Relationships with Payers

Healthcare providers should focus on building better connections with payers to speed up the insurance credentialing process. This means keeping in regular contact with payer officials and quickly informing them about any changes that could affect credentialing.

Here are some key areas for providers to focus on:

• ➜ Talk Directly to Payer Staff: Reach out to the payer credentialing team. This can help clarify any confusing requirements and ensure you understand what’s needed. Having a specific contact person can also make it easier to check on the status of your applications and resolve any issues that might delay acceptance.
• ➜ Keep Payers Updated: It’s important to inform payers about any changes to your details. This includes updates to credentials, locations, affiliations, licenses, and more. By giving timely notice, payers can quickly update their records, which helps prevent administrative hiccups that could slow down the process.

By sharing clear information and delivering frequent updates, providers can groove their way to solid relationships with payers. This not only jazzes up the credentialing process but also lets providers get the green light faster, so they can jump right into caring for patients with insurance coverage.

Poor credentialing leads to denied insurance claims, legal issues, and unsafe patient care. Therefore, choosing a good credentialing service with mental health expertise and experience is important.

This BellMedEx guide covers key factors to consider when choosing the best credentialing service for mental health providers. We’ll also talk about common mistakes you should not make and clues you can use to stay away from any problems.

13+ Key Factors to Consider When Choosing a Credentialing Service for Mental Health Providers

Look for these things when choosing the best credentialing service for mental health providers:

• Experience and expertise
• Comprehensive services
• Clear performance metrics
• Partnerships and affiliations
• Tech and innovations
• Customizations and flexibility
• Regulatory compliance
• Transparent pricing
• Faster turnaround time
• Improved online reputation
• Staff training and resources
• Ability to scale up or down
• Broad geographic coverage
• Client support and ongoing maintenance

Let us detail down each aspect now.

1. Experience & Expertise in Mental Health Credentialing

When selecting a credentialing service for your mental health specialty, look if it has experience and knowledge of expertise in mental health. An insurance credentialing provider with a proven, relevant track record can effortlessly help a mental health clinician get credentialed and enrolled in premium insurance networks.

Ensure your credentialing partner understands the unique challenges and requirements of different mental health specialties. Don’t choose a credentialing service based solely on cost or recommendations without verifying their experience and expertise.

To confirm the experience and expertise in credentialing for mental health providers, you can ask a series of questions, such as:

• How many years have you been in credentialing for mental health providers?
• Which insurance companies or networks have you worked for credentialing mental health providers?
• What is your process for verifying the credentials of mental health providers?
• What tools or software do you use to manage the credentialing process?
• How do you ensure the accuracy and completeness of credentialing applications?

2. Comprehensive Mental Health Credentialing Services

Look for a mental health credentialing service that offers comprehensive offerings, including primary source verification, background checks, and ongoing monitoring. It ensures that your credentials are always current and compliant, minimizing risks of credentialing errors.

Avoid credentialing providers that offer limited services, as they may overlook essential components. Look for warning signs, such as unclear service descriptions or resistance to detailing their processes.

You might ask these questions to ensure you’re partnering with the right credentialing company.

• What specific credentialing services do you offer for mental health providers?
• Do you handle initial credentialing, re-credentialing, and ongoing monitoring?
• Do you offer a consultation session to understand the credentialing process?
• Do you offer other services such as compliance consulting or audit support?

3. Clear Metrics to Evaluate Credentialing Quality

Choose a credentialing service that offers clear performance metrics and regular updates on credentialing applications. This transparency helps mental health practitioners confirm the service’s reliability and efficiency. Many mental health providers may not consider this when choosing a credentialing service for them, which is a mistake.

When you ask them about it, they may show late responses or a lack of structured reporting. Reliable performance metrics will help you track progress, identify issues early, and ensure a smoother credentialing process.

Always ask for details about their KPIs by asking these questions:

• What’s the length of time for a provider to submit an application?
• What’s the number of initial credentialing files returned for additional verification?
• What is your success rate for initial credentialing and recredentialing?
• What is the average turnaround time for completing the credentialing process?
• How do you track and minimize errors in credentialing applications?

4. Partnerships with Major Insurance Networks for Mental Health

Consider whether the credentialing service has strong partnerships with major insurance networks and professional organizations. It helps facilitate a smoother credentialing process, giving mental health professionals access to important in-network contracts. Failing to verify this could limit your mental health practice’s opportunities.

A provider with strong affiliations can improve your mental health clinic’s visibility and expedite your credentialing journey. Don’t hesitate to ask these questions when your choose a credentialing service as a mental wellness expert:

• Which insurance networks and payers do you have relationships with?
• How do you stay updated with the credentialing requirements of payers?
• Can you provide case studies from mental health providers who have successfully been credentialed with major insurance networks through your services?
• Do you help with negotiating contracts and advocating for mental health providers with relevant insurance networks?

5. Technology and Innovation for Therapy Credentialing

Select a mental health credentialing service that employs much needed software and tech solutions to streamline the process and reduce errors. A common mistake is choosing a provider with outdated systems, which can lead to unnecessary delays.

An innovative credentialing provider will use automation, user-friendly platforms, and integration with your existing systems to simplify the credentialing process. This also ensures solid data security and compliance with regulations like HIPAA.

Confirm if your mental health credentialing partner has outdated software, lack of cloud-based systems or inadequate data security measures.

You can ask these questions to analyze their tech solutions:

• Does the credentialing system integrate with our existing EHR and PMS?
• Can you provide examples of recent automation or innovation you implemented?
• How does the credentialing partner ensure the data security and confidentiality of mental health providers and patients?

6. Custom and Flexible Credentialing Solutions for Mental Health

Each mental health facility has unique needs, and a one-size-fits-all approach often falls short. Look for a credentialing service that adapts its offerings to fit your needs. You as a mental health provider should not assume all services will meet your needs.

Run away from the credentialing partner if it shows lack of willingness to discuss tailored options. A customized approach ensures that your credentialing process aligns perfectly with your practice’s goals and changes.

Ask these questions to confirm your credentialing partner’s customization and flexibility:

• Can the credentialing process be customized to meet the specific needs of my mental health practice (e.g., psychiatrists, psychologists, counselors)?
• How flexible is your credentialing service in terms of scaling up or down?
• How quickly can you adapt to changes in regulatory requirements or your practice’s needs?

7. Regulatory Compliance for Mental Health Providers

Staying compliant with regulations extremely important in healthcare. Mental health providers must adhere to high standards, and failing to do so can cost you delays and potential legal issues.

Ensure that the credentialing service you choose is well-versed in the latest mental health regulations. Don’t overlook the importance of accreditations like NCQA or URAC. Be cautious of credentialing providers that don’t clearly explain their compliance processes or show a lack of understanding of state and federal regulations.

You can ask these questions to confirm their stance on compliance:

• Do you offer credentialing support during audits and inspections?
• How do you ensure credentialing compliance for mental health providers?
• What kind of documentation and reporting do they provide to ensure compliance?

8. Transparent Pricing for Credentialing Mental Health Practices

While it’s tempting to go for the lowest price, remember that quality often comes at a higher price. Credentialing is an important service that impacts your mental health career and practice.

Look for transparency in pricing to avoid hidden fees and unexpected charges. Stay away from mental health insurance credentialing services that provide unclear pricing structures or push low-cost options without explaining their limitations.

A thorough ROI analysis will help you determine if a higher-priced service is worth it for the efficiency and expertise it brings. You can also ask these question:

• Is your pricing structure transparent, with no hidden fees?
• Can you provide case studies of cost savings achieved for other clients?
• Do you offer flexible payment plans or discounts for long-term contracts?
• Are there other services included in the cost that add value to my practice?

9. Faster Turnaround Time for Credentialing

Quick processing times help maintain your mental health practice’s operations. On the other hand, delays in credentialing can lead to lost revenue and hinder your ability to provide care. Don’t be afraid to ask about turnaround times upfront.

Confirm a credentialing service’s average processing times and the measures they have in place to expedite the process. A provider with efficient workflows can reduce credentialing time, allowing you to focus on patient care sooner.

You can ask these questions to have an idea of the turnaround time:

• What is the average time taken to complete the credentialing process?
• Do you offer expedited credentialing, and if so, what is the additional cost?
• How do you update clients about the status of their credentialing applications?
• How do you handle delays in the credentialing process?

10. Improved Reputation and Positive Reviews

Checking a provider’s reputation through reviews and testimonials is a valuable step in your decision-making process. Online reviews can provide insights into a credentialing service’s reliability and effectiveness.

Don’t solely rely on the provider’s testimonials reviews. Look for overly positive reviews that may be scripted. Run away from the credentialing provider if there’s lack of reviews or consistent complaints across different platforms.

Researching industry recognition and speaking with current clients can provide a well-rounded view of the provider’s reputation.

Ask yourself these questions:

• Are there positive testimonials or references from other mental health providers?
• What do online reviews and ratings on platforms like Google, Yelp, and other industry-specific sites say about their credentialing services?

Ask the credentialing service these questions:

• How do you handle complaints or negative feedback from clients?
• What is your client retention rate, and what feedback do you receive from long-term clients?

11. Mental Health Practice Staff Training and Resources

A credentialing service should provide training and resources for your staff. The credentialing process involves many forms and documentation. Missing paperwork delays your credentialing application, causing frustration and setbacks.

Look for credentialing providers that offer staff training programs and continuous education opportunities. Don’t assume your team knows the requirements. You can ask the credentialing provider these questions:

• Do you provide any resources or training materials to help clients understand the credentialing process?
• What kind of training do your staff undergo to stay updated on credentialing requirements and best practices?
• Are there opportunities for ongoing education or updates for clients regarding changes in credentialing requirements?
• Can clients access credentialing experts for consultations or questions during the process?
• Do you offer guides, webinars, or workshops to assist clients with the credentialing process?

12. Scalability According to Mental Health Practice’s Needs

As your mental health practice grows, your credentialing needs may change. It’s important to choose a credentialing service that can scale up or down its offerings accordingly.

Look for a credentialing outsourcing company that takes the time to understand your specific situation and can adjust their services as you expand. Stay away from credentialing providers that are not willing to discuss customization and scalability.

You can ask them these questions to be clear about their scalability:

• How do you manage an increase in the number of your clients?
• Can your credentialing services be scaled up or down based on our needs?
• How do you plan to see future growth and changes in the healthcare industry?

13. Broad Geographic Coverage of Credentialing Services

Looking for a broad geographic service area for credentialing is important, especially if your mental health practice has multiple locations or offers telehealth. Each state has its own requirements, so verify that the provider understands local regulations.

Credentialing providers with broad geographic coverage will adhere to different state laws, licensure, and insurance networks. And they help facilitate smoother credentialing processes and better relationships with local payers.

Avoid credentialing providers with vague knowledge about state-specific credentialing rules or an inability to manage multi-state credentialing.

You can start asking these questions to confirm the service area of your potential credentialing partner:

• Which geographic areas do you cover?
• Do you have expertise in the credentialing requirements to different states?
• How well-connected are you with local insurance providers?
• Are there plans to expand your services to new regions or states?

14. Credentialing Client Support and Ongoing Maintenance

Insurance credentialing for mental health providers is an ongoing process, not just a one-time task. Choose a service that offers excellent support for re-credentialing and updates for your mental health practice. Responsive customer service helps prevent delays and address issues.

Look for providers that assign dedicated account managers for consistent communication. And run away from those that show slow response times or a lack of a collaborative approach. A supportive partner will help maintain your credentials and ensure compliance. 

• What kind of customer support do you offer?
• Do you provide ongoing maintenance and re-credentialing services?
• What channels (phone, email, chat) are available for clients to reach out?
• How do you inform your clients about changes in credentialing requirements or regulations?
• Is there a system in place for clients to provide feedback on your credentialing services?

Conclusion

To conclude, proper credentialing lays a strong foundation for mental health practices to thrive. It not only opens doors to insurance contracts but also minimizes compliance risks. Use this BellMedEx guide to make an informed decision when selecting a credentialing service.

Look for comprehensive offerings, innovative tech, customization, and responsive support. Steer clear of vague providers lacking transparency or expertise. Invest time in finding the right partner so you can devote energy to your passion of caring for patients. With rigorous credentialing, mental health providers gain peace of mind and practice success.

Do you want to help more patients and make your treatment better? Insurance paneling can help you a lot! More people can use your health care services when you join well-known insurance companies via insurance paneling.

Are you not sure what to do with the process of medical insurance paneling? Remember not to worry!
We’re here to help you all the way through.

Get to know the people who are giving out credentials i.e. the credentialing panel. It tells you what to do and what paperwork is needed to verify your skills. It will also help you meet the standards if you know the paneling rules for each insurance company.

Follow these simple steps to learn about insurance panels and help your practice grow. Let’s start!

Get paneled with any insurance company of your choice!

Schedule Free Consultation

Understanding Insurance Paneling In Healthcare

An insurance panel refers to the list of healthcare providers that a health insurance payer (e.g. insurance company) has contracted with to provide medical services to its members at pre-negotiated rates. Joining an insurance panel means that a healthcare provider, such as a therapist, psychologist, or counselor, has entered into an agreement with a health insurance company to become an in-network provider for that insurer.

As an in-network provider, the healthcare professional agrees to the insurer’s contracted rates for services rendered to the insurance company’s members. In return, the provider gains access to the insurer’s covered patient population, with the advantage that patients face lower out-of-pocket costs for services from in-network providers compared to out-of-network providers.

Important terms related to insurance panels include in-network providers, who are healthcare professionals that have joined an insurer’s panel, and out-of-network providers, who have not contracted with a particular insurance company. Health insurance payers create provider networks by credentialing and contracting with providers who meet their criteria.

In contrast, providers who remain out-of-network do not join insurance panels. Out-of-network providers can set their own rates and are not bound to the terms and conditions set by insurers. They provide services to patients covered by that insurance, but the patient must pay upfront and submit claims themselves to seek reimbursement from their insurer at the out-of-network rate. Here the provider does not get paid directly by the insurer.

Step-by-Step Process for Getting Paneled with Insurance Companies

When you get paneled with an insurance company, you agree to work with them as a provider for a certain health insurance plan. After this insurance paneling, patients with a certain health insurance plan can come to your practice for care, and you can bill their insurance company for it.

Do not forget! Remember! Insurance companies only prefer paneling those healthcare providers who can help them manage healthcare costs. They are always on the lookout for medical service providers who will take less money. In contrast, health care workers want to work with insurance companies that will pay them more for their services. So finding the perfect insurance company to get paneled with becomes challenging for a doctor, but not impossible.

Here is a step-by-step guide on how to get paneled with insurance companies as a healthcare provider:

Step 1: Getting Your Documents Ready

Before applying to get paneled with insurance companies, you will require a lot of information and documentation. It is crucial to arrange these documents to avoid any kind of delay and denial in your application approval.

The documents are:  

• Licensure information
• Practice address
• NPI number
• Resume
• Proof of malpractice insurance
• Taxonomy code (if you plan to bill Medicare/Medicaid)
• Proof of liability insurance from your landlord (if you rent)
• Advanced training or credentialing paperwork (if you have any)

Step 2: Searching For Different Insurance Companies

Now as you have arranged all these documents, it’s time to look for different insurance companies. Keep in mind that each insurance company has its own rules and payment rates. Even some of the companies require years of experience before they’ll sign insurance paneling agreements with you.

Therefore, before you look for an insurance company, here are some important things to keep in mind:

Network Size — Look for insurers with large coverage networks in your geographic area to gain access to more potential patients. Larger insurers like UnitedHealthcare, Aetna, and Blue Cross Blue Shield often have expansive networks.

Reimbursement Rates — You should compare the rates that different insurers offer for the typical procedures you do. Higher rates mean more revenue per patient visit. Get the fee plans from each insurance company to help you decide which one to go with.

Experience Requirements — Some insurers require 1-2 years of practice experience before they will accept you as a provider. Therefore, when choosing an insurance company, you should look at these requirements and pick one without strict experience requirements.

Credentialing Timeline — Keep in mind that provider insurance paneling process could take 3 to 6 months. Therefore, we advise you to pick plans like Cigna and Humana that can get you credentialed faster so you can start sooner.

Payment Reliability — Make sure that insurance companies pay claims on time. You can find out about this by reading online reviews and asking coworkers about their own experiences. This step is very important because it will help you make steady money, which is important for any healthcare business.

Plan Types — Determine which types of plans are dominant in your area – PPOs, HMOs, EPOs, etc. After that, focus on insurance companies that offer those specific plans to get in touch with more patients in your target area.

Value-Based Care Initiatives — Check with each insurance company to see what role they play in value-based care models, such as responsible care organizations (ACOs) or patient-centered medical homes (PCMHs). These programs can change how care is given and how much is paid for it.

Administrative Support — Last but not least, look for insurance companies that offer helpful tools like online portals, electronic claims filing, and specific reps for providers. This help could make it a lot easier for your team in the administrative process.

In addition, applying to 3-5 insurance companies that align with your geographic location, specialties, experience level, and business needs can position your practice for success as an in-network provider.

Step 3: Submitting The Credentialing Application

Health care workers must send a separate application to each health insurance company they wish to work with in order to begin the provider credentialing and paneling process.

Now, here’s a handy tip: many insurance companies use the Council for Affordable Quality Healthcare (CAQH) for provider insurance paneling. The streamlined application system created by CAQH is called CAQH ProView, and it really helps providers get their credentials more quickly.

Once you’ve sent your application via CAQH, the insurance company you’re targeting will provide you with a unique application number. This number is quite useful because it allows you to see where your application stands in the credentialing process and helps you keep track of everything.

The CAQH ProView application serves as a centralized repository for your professional and practice information. This means you won’t have to submit separate applications to multiple insurance companies, which is a real time-saver. This feature reduces administrative burden and ensures consistency in the information you provide to payers.

Now, it’s very important to get the entry form right. Make sure to include all the necessary documents, such as your professional license, certifications, malpractice insurance, and details about your business. Paying close attention to every detail when you apply will help speed up the process.

Step 4: Following Up After Application

Once you send your insurance paneling application to the health insurance company, you should check back soon. Most insurance companies will give you an idea of how long it will take to get your credentials, which is generally between 4 and 6 weeks. Check in with the provider relations group again in 4 weeks to see how your application is going.

Make sure you have your NPI number, Tax ID number, and application reference number with you when you follow up. Make sure they got your complete application. This includes everything that is attached, like licenses, certificates, liability insurance, and a DEA certificate. Make sure that no more information is needed to finish the process of getting credentialed as an in-network provider.

If the application is still being worked on, follow up again in 6 weeks. Always following up in a professional way lets them know that you want to be a part of their network.

If your application is turned down, request the reasons in writing. Not having enough malpractice insurance or not being eligible for Medicare are some common reasons for rejection. Fix any issues and try again.

In your subsequent application, mention improvements like extended hours, bilingual staff, EMR systems, or new services offered. Joining provider panels can take persistence through multiple application cycles.

You can finish the process quickly if you keep checking on your credentialing application. Checking status routinely demonstrates your commitment to the insurer’s network and patients.

Step 5: Reviewing The Terms of Approval

Once insurance companies agree to let you join their network of providers, it’s important to read the terms and conditions carefully before signing any contracts. This will help keep problems from happening in the future.

Key things to look over:

Reimbursement Rates — Look over the fee schedules for your specialty to make sure the rates of reimbursement are fair. Keep a close eye on the relative value units (RVUs) that go with the CPT codes you bill most often.

Billing and Coding — Make sure you can meet all the standards for billing and coding. You should know what variations, CPT codes, and ICD diagnostic codes are accepted. Also, look over how to submit claims, when they need to be sent, and whether electronic or paper claims should be used.

Authorization Requirements — Write down any permissions, referrals, or other paperwork that you need to get before you can perform certain medical services or procedures.

Contract Exclusions — Look out for exclusions for medical services, procedures, diagnoses, or types of providers that you might want to offer.

Appeals Process — Understand the process and timeframes for claim appeals and denials.

Penalties — Carefully review any fines, fees that need to be paid back, or other punishments for not following medical billing rules or other terms.

Provider Portal Access — Make sure you can get to the portals that let you check on things like a patient’s eligibility, the state of their claims, the authorization requirements, and more.

Checking the contract terms carefully before signing will help you avoid problems and make sure the process goes smoothly with the payer. Use the network contract checklist and also have a lawyer look it over.

Some Important Tips

Here are some important things to keep in mind that could make it easy for you to get on the insurance companies’ lists and keep you out of trouble.

Get Board Certification

Getting board certification is an important step you don’t want to skip if you want to be accepted by big health insurance companies. This license is very important because it shows that you’ve been trained and tested very carefully in your field. It’s all about showing that you meet the high standards of ethics and practice that insurers want to see.

Most big insurance companies need this license to make sure that the doctors in their network are providing good care. So, when you’re done with your residency, you can choose to take an exam in your field, whether it’s internal medicine, pediatrics, or something else. Passing that test shows that you know what you’re talking about and are dedicated to keeping updated in your field.

Certain smaller insurers might not need board qualification right away, but having it makes you much more competitive. It’s a great way to show that you are committed to giving excellent care that is based on convincing evidence. So, you should definitely think about it!

Consider Intern Policy

When working with insurance companies as a healthcare provider, it is important to carefully consider your intern policies. Unlicensed interns, even if they have finished their degrees, are often not credentialed to bill for services on their own. In some states, Medicare and Medicaid let billing happen under a supervisor. But in other situations, this might be considered insurance fraud. To prevent problems, look up the laws in your state and understand the insurance policies for interns from each insurance company. If you check the rules carefully at the start, you can feel sure about making internship opportunities that follow billing regulations.

Know The Required Time

When you apply to work with insurance companies, it is important to know how long they take to review and approve your application. Every carrier has its own rules about how long the vetting process will take. Check how long it usually takes to get things done. This will help you know what to expect. Knowing the needed time helps you check in at the right times. During the paneling process, there are often many requests back and forth. It is important to keep track of response times to avoid delays on your side. Following the insurer’s schedule shows your professionalism and dedication to building the partnership.

Remember Previous Disciplinary Action (if any)

When you apply to get paneled with insurance companies, it is very important to be honest about any past disciplinary actions against you. Having a record of discipline does not mean you will be disqualified. However, if you do not tell about it, it can hurt your trustworthiness and slow down the approval process. Insurance companies will check your background very carefully, so being honest is always the best choice. Explain what happened with the discipline and highlight the good actions you have taken since that time. Showing that you have grown and take responsibility can help reduce worries. If you are honest and clear, you can still be accepted even if you had a past issue.

Know If You Are A New Licensee

Some insurance payers like to choose providers who have many years of experience before bringing them on board. As a new licensee, find insurance companies that accept new practitioners. You might also think about starting with Medicaid or Medicare if your state permits new providers. Build up your patient roster and get that initial experience. In one or two years, you will be better able to meet stricter requirements from commercial insurers. Do your homework first. This way, you won’t waste time applying to panels that will not accept you.

Stay Informed

For healthcare workers, getting on the panels of insurance companies is a big deal, but it’s only the start. Learn the most recent rules and guidelines from these insurance groups. This is the most important thing you can do to keep a friendship going on with them.

Insurance firms are very active and often change their rules to keep costs low and help people get good care. Stay alert and watch for these changes. It will be simple to make your business fit what they want. Through trust and following through, this builds a strong connection that lasts. It also makes sure that you can keep your services running. Be ready to learn something new all the time. Read insurance company papers, go to their seminars, and communicate with the relevant people in your field every day.

Benefits Of Getting Paneled With Insurance Companies

Getting paneled with insurance companies brings many benefits to healthcare providers. The most notable of them is that it opens windows to new opportunities, and assists you to grow footfalls of patients to your practice.

It Gets You More Patients.

When you join a lot of different insurance networks, you can get more patients who can use their plans to find your healthcare office and get care services.

It Boosts Your Chances Of Making Money.

More people will be able to get medical care from you if you are on the panels of more insurance companies. With this, you may be able to potentially make more money.

It Makes It Easier For People To Get Multiple Care Services.

You can make it easier for people to get a variety of low-cost medical services. People who really need care but can’t pay for it will benefit from this.

It Improves Your Professional Image.

One way to boost your credibility as an insurance agent is to be in network with respectable firms. This proves that your schooling, experience, and license are at the very best level required by these insurance companies.

Still Doing Credentialing Yourself? Stop the Madness!

Credentialing is a beast. It’s time to stop the do-it-yourself madness!

Our medical credentialing service empower you to see patients months sooner than doing it yourself.

No more staying late or working weekends on credentialing. Outsource to us and take back your evenings and weekends!

Schedule Free Consultation

---

Assisting with billing, credentialing and enrollment, BellMedEx has been consistently reliable from the first day of our relationship.

Dr. Mike

Internal Specialist Medicine

Top Features

✓ Provider Enrollment
✓ Provider Credentialing
✓ Provider Privileging

It increases enrollment turnaround times, decreases paperwork, and expedites timely reimbursement. The insurance company also takes less time to decide whether to take a provider on its panel or not.

This comprehensive guide will help you understand everything you need to know about delegated enrollment and credentialing.

What is Delegated Credentialing?

Delegated credentialing is an arrangement in which a healthcare entity gives its credentialing authority to another healthcare entity. For example, a preferred provider organization may legally ask a hospital to credential its providers.

The delegated healthcare entity becomes responsible for taking credentialing decisions on the delegating healthcare entity’s behalf. They can verify provider’s qualifications, state licensure, DEA registration, work history, and more.

A delegated healthcare entity is responsible for reviewing and analyzing provider’s qualifications and making credentialing decisions on behalf of delegating entities.

The delegated entity may require this data:

• Professional Liability Claims Settlement History
• CDS (Controlled Dangerous Substance) Certification
• Education Malpractice History
• DEA Registration
• Sanctions & Exclusions
• Disclosure Questions
• Board Certification
• State Licensure
• Work History
• Hospital
• Attestation

But remember that a delegating entity is ultimately responsible for compliance with regulatory bodies, federal, and state laws.

Who Can Delegate Credentialing and Be Delegated?

There are two major healthcare entities involved in delegated credentialing:

1. Delegated entity
2. Delegating entity

These healthcare organizations can be delegated:

• Provider Groups (single or multi-specialty or multi-location)
• Independent Physician Associations (IPA’s)
• Hospitals & Hospital Systems
• Specialty Provider Networks (Dental, Vision)

And these healthcare organizations can delegate:

• Provider Networks
• Independent Physician Associations (IPA’s)
• Preferred Provider Organizations (PPO)
• Health Plans (Cigna, Aetna, etc)
• Accountable Care Organizations (ACO’s)
• Specialty Provider Networks (Dental, Vision)

Fun Fact: Some entities like IPAs and SPNs can delegate and be delegated as well.

Not sure whether your healthcare organization can delegate or be delegated? Schedule a free consultation session now to learn everything you need before getting started with delegated credentialing.

Some Examples of Delegated Credentialing

Delegated credentialing is an arrangement where one healthcare organization lets another organization handle the credentialing process for them. It’s a way to streamline things by having a larger entity take care of the administrative work for smaller groups. Let’s look at a few examples to understand it better:

Example #1

Dr. Smith works at Community Hospital but also sees patients at the local clinic run by Metro Health Network. Instead of Dr. Smith having to go through credentialing twice, Metro Health allows Community Hospital to credential him on their behalf. This saves time and duplication of efforts.

Example #2

As another example, many health insurance plans don’t directly employ physicians. Instead, they contract with independent doctor groups and healthcare organizations to provide care for their members.

The insurance plan will delegate the credentialing of those outside doctors and groups to a third-party credentialing agency. That agency becomes responsible for ensuring all the doctors meet the insurance plan’s requirements before they can officially join the plan’s network.

This helps the insurance plan quickly build a network of high-quality doctors without investing in their own credentialing department.

What is a Delegated Provider in Credentialing?

A delegated provider in credentialing refers to the provider that was given the responsibility of credentialing another provider or organization. That is not usually the individual provider but a full-fledged healthcare organization.

What is an Authorized Agent?

Authorized agent is any entity elected by eligible healthcare entities to process delegated credentialing and query the NPDB (National Practitioner Data Bank) on their behalf. Remember the authorized agents may act for more than one entity.

What is a Delegated Entity in Healthcare?

Delegated entity in healthcare is the entity to which the administrative responsibilities were delegated by another healthcare entity (called the delegating entity). However, the delegating entity oversees the entire process to ensure accuracy and compliance.

A delegated credentialing entity is any party that enters into a delegated credentialing agreement with a delegating entity. It’s the entity that has been given the authority to credential the healthcare providers of a (delegating) credentialing entity.

What is a Delegated Credentialing Agreement?

A delegated credentialing agreement is a written document that outlines all the credentialing responsibilities to delegated and delegating entities. The agreement is important because some functions in credentialing remain in-house. But mostly, the entire credentialing process is delegated to an entity.

The agreement for delegated credentialing also details down the managed care standards, termination rights, required reporting, and more. For example, the required reporting section of the agreement shares things that need to be reported, including complaint monitoring, semiannual credentialing activity, and more.

Delegated vs Non Delegated Provider in Healthcare

The difference between delegated and non delegated providers in healthcare credentialing is the existence of delegated credentialing entities. Non-delegated providers are the ones whose credentialing is done by their associated healthcare facility. The process is called credentialing.

In non-delegated credentialing, the healthcare facility collects credentialing information from its associated providers for their credentialing. In delegated credentialing, the outside entity does this job in accordance with the written agreement.

Delegated Credentialing vs Credentialing by Proxy

Delegated credentialing transfers the credentialing authority from one entity to another, while credentialing by proxy (CBP) refers to the credentialing of telehealth or virtual healthcare practitioners.

CBP allows the prime source verification, meaning hospitals using virtual healthcare services can accept the credentialing work of the remote hospital. They don’t need to implement the full credentialing for providers who never visited or sit in the hospital.

Regulatory Bodies Involved in Delegated Credentialing

There are three major regulatory bodies and stakeholders that ensure quality, compliance, and patient safety in delegated credentialing.

1. NCQA (National Committee for Quality Assurance)

NCQA sets standards for healthcare quality and performance improvement. Their guidelines are considered crucial in ensuring that credentialing processes meet high standards of reliability and accuracy. Healthcare organizations align their practices with NCQA standards to increase credibility and quality assurance.

2. CMS (Centers for Medicare & Medicaid Services)

CMS oversees federal healthcare programs including Medicare, Medicaid, CHIP, and ACA-related initiatives. It also imposes regulatory requirements for healthcare entities involved in delegated credentialing, complying with federal laws, safeguarding patients, and ensuring billing integrity.

3. Local Government and Verification Processes

Healthcare entities and authorized agents may need to follow some rules set by local governments. For example, you need to verify credentials directly from primary sources such as medical schools, licensing boards, and previous employers. Meeting deadlines and following such guidelines are important in obtaining and maintaining delegated credentialing status at the local level.

Delegated Credentialing Requirements for Time

The NCQA and other regulatory agencies have many requirements and standards. And the most important ones are being strict on time frames for the primary source verifications (PSV) as listed below. 

This is just the PSV time requirement, look up the delegated credentialing agreement for a comprehensive list of requirements.

Delegated Credentialing Process (How Does Delegated Credentialing Work)

Your healthcare facility must abide by different requirements, especially set by NCQA, to participate in a delegated credentialing arrangement.

Delegating entities can also set their own standards for delegated credentialing.

Setting and following the process is important also because the regulatory bodies require certain elements for delegated credentialing, such as pre-delegated assessment, oversight audits, and more.

Here’s how to implement delegated credentialing:

1. Develop an Internal Credentialing Program

Make policies and procedures compliant with state, federal, and payer regulations. Establish a robust quality oversight program involving medical staff services, quality department, peer review committees, and other stakeholders. Allocate necessary resources including personnel, operational infrastructure, and credentialing software.

2. Complete Pre-Delegation Assessment

Conduct an initial audit to evaluate policies and procedures against NCQA, URAC, or CMS managed care standards. Review a sample of initial and re-credentialing files to ensure compliance with credentialing criteria. Assess staffing levels and performance capabilities to ensure all processes align with regulatory requirements.

3. Negotiate Delegated Agreement

Define and document the responsibilities of both parties (health plan or delegating entity and delegated entity) about credentialing activities. Agree on the frequency, content, and format of credentialing activity reports to be submitted to the health plan.

Clearly decide on how you will analyze performance and resolve non-compliance issues. Determine reimbursement rates and fee structures applicable under the delegated credentialing agreement.

4. Conduct Credentialing

Utilize a robust credentialing software to verify qualifications, licenses, certifications, and other credentials of healthcare providers. Maintain accurate and up-to-date provider rosters detailing status changes, new enrollments, and terminations. Submit provider rosters to health plans in the required format and within specified timelines.

5. Participate in Annual Oversight Audits

Prepare for annual oversight audits conducted by NCQA, CMS, or health plans to evaluate compliance with credentialing standards. Review policies, procedures, and credentialing files to ensure adherence to regulatory and accreditation requirements. And in case of any discrepancies, implement corrective action plans to maintain compliance and contractual obligations.

Pros and Cons of Delegated Credentialing

Delegated credentialing offers many benefits but also requires careful management of responsibilities, compliance, and oversight to ensure smooth operation.

Benefits of Delegated Credentialing

• Saves time and resources for health plans overwhelmed with new enrollments.
• Lowers costs compared to hiring internal credentialing staff.
• Reduces turnaround time, allowing quicker enrollment of providers.
• Leads to quicker reimbursements for delegating entities.
• Enables new providers to start quickly, improving patient care.

Downsides of Delegated Credentialing

• Health plans (delegating entities) may lose control over credentialing quality.
• Changes in payer requirements can cause confusion if not managed carefully.
• Delegating entities bear responsibility for credentialing decisions.
• Many health plans mandate NCQA accreditation for delegates.
• Routine NCQA audits add to administrative burdens.

Streamline Delegated Credentialing With BellMedEx

BellMedEx offers comprehensive delegated credentialing services and can act as an authorized agent to streamline all things credentialing and enrollment. We optimize the delegated credentialing process for healthcare organizations to ensure efficiency and accuracy, compliance, and administrative relief.

Get free consultation on how we can help you improve your revenue cycle and increase patient satisfaction with our leading delegated credentialing solutions.

The terms “payor enrollment” and “payor credentialing” are often used interchangeably in healthcare industry. Enrolling payors and verifying their credentials is complicated, and it gets tougher with each passing year. 

Your cash flow will suffer due to improper enrollments and credentialing so the revenue cycle management platform will not function properly. Payor credentialing services involves verification of a healthcare provider’s qualifications for inclusion in a network of doctors. Hospitals and health systems also do medical credentialing to ensure that a clinician’s training, certifications, and professional experience are up to date.

How to Accelerate Payor Credentialing?

Payor enrollment goals align with revenue integrity priorities, such as coding, charge capture, financial projections, optimized payments, and spending as little time as possible fixing avoidable claim errors. If you keep the following points in mind, the credentialing process will go much faster:

Automated Payor Transactions

The process of credentialing and enrolling a new provider can be time consuming. Automation technology, has the potential to make this process more efficient for you and your staff. Each provider is required to submit a variety of forms. There are several tools available to help you automate the form completion process associated with enrolling in a new provider. In provider credentialing, verifying the information provided by the providers takes time as well. This task is made more efficient by automation technology. The majority of your provider credentialing process can undoubtedly be speed up with automated data verification.

Contracts with Payors

Managing payor contracts is one of the primary challenges that every healthcare provider faces. Payer contracts describe a provider’s reimbursement arrangement for providing healthcare services to patients covered by a particular health plan. Understanding complex payer contracts is essential for ensuring accurate and timely reimbursement. Payer contracts include fee schedules, reimbursement criteria, and terms for timely reimbursement.

Centralized Provider Data

Inaccurate or incomplete information about a provider’s professional certifications, work history, or malpractice insurance causes lengthy credentialing and enrollment delays, resulting in member access issues and revenue loss. After providers have been enrolled, they must keep their information up-to-date regularly. Within 90 days, all other changes must be reported.

Using a centralized source of verification that is consistently reconciled and dynamically validated against primary sources is helpful to maintain clean, accurate provider data. The centralization of real-time provider data improves data quality, accessibility, and transparency and reduces provider frustration by eliminating duplicative requests for information.

Quality Review

The entire payor enrollment process is mapped internally for quality review. It’s critical to map the provider enrollment process from the recruiting stage to final payor approval. It’s critical to hold the payor accountable for what they promised in the signed contract from the outside. Consider the following inquiries:

Is the process completed within the allotted time?
Are the payor directories up to date and easy to find?
Is the payor providing the level of service that is expected?
The details of how the payors will be held accountable for their errors and failures must be included in your plan of correction.

Although the enormity of incorporating the payor enrollment team into the revenue integrity department cannot be fully summarized in five steps, these best practices can help ensure that all reimbursements associated with payor enrollments are collectible.

If you’re looking for a way to speed up the provider credentialing process in 2022, outsourcing your payor enrollment credentialing is one of the best options. Credentialing services providers are experts at navigating this process, so they save time by ensuring everything is done the first time correctly.

Keep in mind that any delays in the credentialing process can hurt your practice’s bottom line. As long as a provider is uncredentialed, they are merely a cost to the practice rather than a source of revenue. While the process can be lengthy and tedious, there are ways to shorten it by mitigating delays.

Begin the process early, double-check that you have all the necessary data, avoid common mistakes, and keep track of the process with payors. Consider outsourcing your payor enrollment credentialing to save time and money.

Streamlining Payor Enrollment:

Payor enrollment credentialing is a time-consuming process that can take months to complete. Payors typically take 90 to 120 days to complete provider credentialing alone, taking months on average to complete the entire payor credentialing process. Provider enrollment may take even longer for smaller plans with limited resources. Healthcare organizations aggravate the situation by failing to collect all required documents for credentialing and making multiple attempts to complete payor enrollment. As a result, when workflow inefficiencies add time to an already lengthy process, organizations are likely to experience delays in claims reimbursement.

Why Do You Need a Reliable Credentialing and Enrollment Process for Your Providers?

Bellmedex is here to ensure that your office gets its credentials promptly and accurately so that you can start receiving reimbursement immediately. We have the experience and knowledge to help you get through the process with the least amount of stress possible. All your office needs to do is provide us with the necessary information and documents, and then we’ll take care of the rest!

By reviewing and gathering documentation to determine the provider’s participation in the health plan, the best healthcare revenue cycle management partner helps you simplify the payor credentialing and enrollment process. The headaches of submitting and tracking payor enrollment credentialing applications based on insurance plan requirements are eliminated with a dependable and efficient enrollment credentialing system.