Insurance Credentialing 101 - Management Resource Group, LLC Insurance Credentialing 101 - Management Resource Group, LLC

Insurance Credentialing 101

What is insurance credentialing?

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MRG will help you navigate the credentialing process

Insurance credentialing, often times referred to as provider enrollment, is the process of becoming affiliated with an insurance company as an in-network/participating provider. Accurate credentialing and enrollment is a critical part of starting and maintaining a medical practice to receive payment for services rendered. Insurance credentialing can often be a financial burden if the applications are not completed timely and correctly.
It is important to understand the credentialing terminology commonly used. At some point, a provider will be faced with the following questions:

  • Are you a sole proprietor, part of a corporation or a partnership? These terms relate to the legal entity out of which you practice medicine.
  • Are you already an established provider who is licensed in the state where you will be providing services?
  • Will you be filing under your own Employer Identification Number (EIN, also referred to as Tax Identification Number or TIN) or will you be working under an established group and need your benefits reassigned to their EIN?
  • Are you changing your EIN, adding additional service locations or service lines, or changing your “pay to” or correspondence address?
  • Have you received a request from an insurance carrier to re-validate or re-attest the information the carrier has on file about you or your practice? BC/BS, for instance, generally requires re-attestations be completed every three years while Medicare requires this every five.
  • Is the information regarding your credentials on CAQH (Council for Affordable Quality Healthcare, Inc) and NPPES (National Plan and Provider Enumeration System) current?

What are some of the considerations and requirements when beginning the enrollment process?

Is the insurance carrier or network accepting new providers? There is no reason to begin the application process if the insurance carrier’s panel is closed, though you should let the carrier know you’re interested in enrolling in case the panel is re-opened.

A provider should be aware of the contracted reimbursement rates for the most frequently utilized CPT codes and inquire if those rates are negotiable. A provider in a specialty practicing in an underserved market may have better results commanding higher reimbursement rates.

A provider must have a current, unrestricted medical license in the state he/she will be providing care. Many carriers will also require the provider to be board certified (or at least board eligible) in his/her specialty.
Physicians are usually required to have established hospital privileges or alternate coverage arrangements at contracted hospitals. These privileges/arrangements must be consistent with the provider’s specialty.
Besides carrying medical malpractice insurance coverage, a provider may also need to provide a malpractice claims history.
Some of the most obvious, but sometimes overlooked requirements is having a physical address for the practice along with a telephone number and bank account in the name of the practice. An IRS Form CP 575, confirming that the IRS recognizes the EIN and entity name along with an NPI (National Provider Identifier issued through NPPES) number linked to the EIN is also a requirement.
A number of carriers utilize CAQH Universal Provider Datasource to obtain provider information in place of an application being completed. The provider or his designee obtains access and uploads the above information, and more, for many payers to electronically access.

What is the timeline?

The credentialing timeline will vary based on the carrier and the acceptance of the provider’s COMPLETED application. Established providers or groups can typically expect to have insurance enrollments completed on average 3 to 6 months from the date the application is accepted. New providers or groups can usually expect this process to take 6 to 9 months. It is always best to begin the process as early as possible due to carrier processing time requirements. That said, some carriers like Medicare will not accept an enrollment prior to 60 days from the effective date of the application. They will, however, retroact the effective date 60 days from the date the application was accepted. (Note that many commercial carriers do not retroact effective dates.)

A provider should consider using an experienced firm to assist with this process, especially if he/she is not familiar with carrier requirements for credentialing. Mistakes and/or omissions will result in lost revenue, or at the very least, delayed reimbursement. Management Resource Group has a dedicated team of credentialing specialists who have worked with every specialty and groups of all sizes, in most states and with most payers.

If MRG can assist with your credentialing needs, please contact Karrie Plaskett at or 888-818-0563 EXT 317.

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