What is the Insurance Credentialing Process?

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The insurance credentialing process is what each provider or facility must go through in order to become a participating provider with a particular insurance company.  The goal of the insurance credentialing process is to become in-network and prevent your patients from having claims go towards their out-of-network deductible or denials.

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Understanding the Insurance Credentialing Process:

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The credentialing process starts by making a request to join the insurance company’s network and submitting your information to them.  Most of the large insurance companies utilize CAQH to access your license, DEA, CV, W9, etc. which means you need to obtain a CAQH ID right away to initiate the credentialing process. Once this request has been submitted, the payer typically takes about 30 days to review your information and determine if they wish to proceed with the credentialing process.  If they do wish to proceed, you’ll be notified that your application is in process and potentially be asked to submit additional information. 

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This is the stage where the payer (insurance company) validates your information and ensures you are who you say you are.  Once through this initial validation process, you then move transition into the contracting phase.  The initial credentialing process (data validation) typically takes around 90 days for most commercial payers.  The contracting phase, on average take another 30-60 days depending on the company, specialty and your location.  South Florida or Los Angeles is going to be slower than in a small town.  So this is the credentialing process in a nutshell but there are obviously many variables and more details associated with it.

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However, the process of getting a provider credentialed with a payer involves a lot of manual work in terms of completing the application forms, providing clarifications to questions from payers and following up with them to close the credentialing request. Trust Onetouch Medical Billing to get you credentialed fasters as we understand the forms required by each payer, and their policies and procedures.

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PROVIDER ENROLLMENT

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Our Provider Enrollment services enable practices to get enrolled for the services they provide by ensuring that payers have the data they need to process claims for the services you provide. We constantly monitor the payers to ensure applications are received and processed on time. We work diligently to identify and resolve potential administrative issues before they impact your provider reimbursements.

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The process involves the following steps:

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• Verification of provider information. Contact payers to determine if they have the correct provider information on file before we submit claims

• Updating practice’s Pay-to address. Validate and update the provider's pay-to address or the billing address

• Enrolling for electronic transactions. Our team can enroll providers for three types of electronic transactions:

  • Electronic Data Interchange (EDI)

  • Electronic Remittance Advice (ERA)

  • Electronic Fund Transfer (EFT) and

• Monitoring process. A group of highly skilled team members trained to perform research and analysis on the possible processor functionality gaps.

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OUR VALUE PROPOSITION FOR PROVIDER CREDENTIALING AND ENROLLMENT SERVICES

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• Keep your data up-to-date with the payer

• Process faster payments from insurance and get more patient referrals

• Mitigate revenue leakage

• Avoid piles of paperwork and filling-up application forms

• Reduce denials and identify provider trends

• Build relationships with different payers.

• Provide real-time status of credentialing and enrollment transactions.