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Credentialing is a verification of your experience, expertise and willingness to enroll in health plans as a participating provider.

Overview:

Family health care Provider credentialing is a complex, ongoing process and a critically important. Without successful credentialing, provider reimbursement for medical services can be delayed or denied.

Even after submitting the myriad documents and forms to a variety of third parties to verify your credentials, please do not think that you are done. You will find that the process consumes hours and hours each year, particularly if you have adopted an inefficient process. The typical physician spends more than three hours annually submitting nearly 18 different credentialing forms and with staff spending an additional 20 hours.

Although a growing number of payers use the CAQH Universal Provider Datasource and credentialing software can reduce the paperwork, most practices still manage this information manually. The process is far from flawless and an increasing amount of practice staff time is spent researching, responding and maintaining credentialing-related files for providers.

The provider enrollment processing time varies by payor. Some commercial plans take as long as 180 days to complete the credentialing process and then another 30 – 45 days for contracting, while other have the entire credentialing and contracting complete within 90 days. When submitting documents for enrollment, contracts, or following up on applications it is important to document your steps, phone conversations with agent names, phone numbers and tracking ID.

JS Medical Billing will provide administration functions and perform credentialing services

New Payer Credentialing:

Apply for all designated payers and follow-up until determination by payer
Update and maintain CAQH database
Update and maintain NPI database
1 year contract (provider may request credentialing with payers up to last day of the contract)
Follow-up until determination by all payers

Credentialing Maintenance:

Update and maintain CAQH database
Update and maintain NPI database
Apply for re-credentialing when due by each payer
Medical License/DEA Registration/expirations 60 day, 30 day, 15 day notification

The following documents are required:

  • All state medical licenses
  • Drug Enforcement Agency Certificate
  • State Board of Pharmacy/Controlled Substance Certification (if applicable)
  • All educational diplomas
  • Board Certificate or Letter of Acceptance
  • Current Curriculum Vitae/Resume
  • Any other documentation required by the client (i.e., W-9, unique provider ID #s, etc.)
  • Hospital Affiliations for a period of up to 5 years
  • Current malpractice coverage
  • Proof of ownership
  • Bank information and voided check

Onetime fee for Initial Set-Up of Physician credentialing file – $250.00

Credentialing/Re-Credentialing Fees per Payer:

  • 1 to 5 Payers – $225.00 (per provider)
  • 6 to 11 Payers – $200.00 (per provider)
  • 12+ Payers – $175.00 (per provider)