General Credentialing Questions
1. What is medical credentialing?
Credentialing is the process of verifying a healthcare provider’s qualifications, training, and professional history to ensure they meet the standards required by insurance companies and other healthcare organizations.
2. Why is credentialing important for providers’ practice?
Proper credentialing is essential for getting paid. Without it, you cannot be an “in-network” provider, which means you cannot bill insurance companies for your services, and patients with those plans may not be able to see you.
3. How often does a provider need to be re-credentialed?
Re-credentialing is typically required every 3 to 5 years, though some payers or states may have different requirements. It is a vital step to ensure all of a provider’s information remains current and accurate.
Process & Documentation Questions
1. How long does the credentialing process take?
The timeline can vary significantly, ranging from 60 to 180 days or more, depending on the insurance payer and the completeness of the provider’s application. Delays can occur due to missing information or slow responses from third parties.
2. What documents and information will I need to provide for Credentialing?
You will need a range of documents, including a CV, state license, board certifications, DEA certificate, malpractice insurance policy, and detailed work history. A complete list is often provided at the start of the process.
3. What is CAQH, and why is it so important?
CAQH (Council for Affordable Quality Healthcare) is an online database that stores a provider’s credentialing data. It’s a critical tool used by many insurance companies to streamline the verification process. Maintaining an accurate and up-to-date CAQH profile is crucial.
4. What is an NPI, and do I need one?
The National Provider Identifier (NPI) is a unique, 10-digit identification number required for all healthcare providers who bill for services. All providers must have an NPI, and it’s a prerequisite for credentialing.
5. What is primary source verification (PSV)?
PSV is the process of contacting the original source of a document (e.g., a medical school, a state licensing board) to verify that the information a provider has provided is true and accurate.
Service & Pricing Questions
1. What if my application is denied?
If an application is denied, it’s often due to missing information or a discrepancy. We work with you to understand the reason for the denial and, when possible, help you through the appeals process.
2. Do you provide credentialing services for my specific specialty?
Yes, we provide credentialing services for a wide range of specialties. Our team has experience working with providers across the healthcare spectrum, from solo practitioners to large group practices. No matter your specialty, we have the expertise to manage your credentialing needs.
3. Do you handle re-credentialing services?
Yes, we proactively manage re-credentialing to ensure your information is always current, preventing any lapses in coverage.
4. Do you offer credentialing services in my state?
We’ve got you covered in all 50 states. Our team is fluent in the specific regulations and requirements of every state, so you can be confident your credentialing is handled correctly and efficiently, no matter where your practice is located.
5. What is your pricing structure?
We offer competitive pricing, either per provider or per panel, with no hidden fees*. We can provide a custom quote after an initial consultation.
Common Challenges & Solutions
1. How can I prevent delays in the credentialing process?
The best way to prevent delays is to ensure all your documentation is complete, accurate, and organized before submitting your application. Working with a credentialing service can significantly reduce these issues.
2. What is the most common reason for a credentialing delay?
The most frequent cause of delay is incomplete or inconsistent information on the application. Any gaps in your work or education history can also trigger a request for additional information from the insurance company, slowing down the process.
3. Can I do credentialing myself?
Yes, but it is a complex and time-consuming administrative task that requires constant follow-up with multiple payers. Outsourcing this process to a professional service can save you significant time and potential revenue loss.