FREQUENTLY ASKED QUESTIONS
We’ve created this Frequently Asked Questions (FAQ) document to help new and established licensed health care professionals understand the process of becoming a solo or group practitioner.
The credentialing process in healthcare is indeed the systematic collection and verification of a healthcare professional's qualifications, licenses, certifications, education, training, and other relevant credentials. This process is crucial for ensuring that healthcare providers meet the necessary standards and have the appropriate qualifications to deliver quality care to patients. Credentialing is typically carried out by hospitals, healthcare organizations, insurance companies, and other entities to maintain a high level of competence and safety within the healthcare system.
Absolutely!
Each of these components plays a crucial role in ensuring that healthcare providers are qualified, competent, and meet the necessary standards to deliver safe and effective care. Here's a breakdown of some key components you mentioned:
Qualifications: This involves assessing the educational background and degrees of the healthcare professional.
Relevant Training: Verification of any specific training programs or courses relevant to their specialty or practice.
Licensure: Checking and verifying that the healthcare professional has the required licenses to practice in their jurisdiction.
Liability Insurances: Ensuring that healthcare professionals have appropriate malpractice or liability insurance coverage.
Professional References: Contacting colleagues, supervisors, or other professionals who can vouch for the healthcare professional's competence and professionalism.
Internships/Residencies/Fellowships: Confirming completion of any required internship, residency, or fellowship programs.
Certification and/or Registration: Verifying any additional certifications or registrations required for the specific specialty or practice.
The credentialing process is a fundamental aspect of maintaining standards and ensuring patient safety in the healthcare industry.
It's a comprehensive list that covers the necessary documentation and information required for credentialing and maintaining accurate professional profiles. This kind of detailed documentation helps in ensuring the credibility and qualifications of healthcare professionals within a network or system.
Training and Education:
Users should provide details about their educational background and any relevant training.
Certifications and Licenses:
Users need to list and verify their professional certifications and licenses.
NPI/Group NPI (If applicable):
Including National Provider Identifier (NPI) information is necessary for healthcare professionals.
Curriculum Vitae (CV):
A comprehensive CV outlining their professional experience, education, and any relevant details.
Malpractice History:
Users should disclose their malpractice history to ensure transparency.
Professional Insurance Liability:
Verification of professional liability insurance coverage.
DEA and CDS Certificate (If applicable):
For professionals authorized to handle controlled substances, providing Drug Enforcement Administration (DEA) and Controlled Dangerous Substance (CDS) certificates.
Medicaid and Medicare Provider ID# (If applicable):
If the professional accepts Medicaid or Medicare, their provider identification numbers should be included.
Admitting Privileges (If applicable):
If the professional has admitting privileges at a hospital, this information is needed.
Completed W9:
Providing a completed W9 form for tax purposes.
Completed CAQH (with no errors):
The Council for Affordable Quality Healthcare (CAQH) form needs to be completed without errors. This is often used for streamlining the credentialing process.
CAQH serves as a valuable tool in the healthcare industry, contributing to the efficiency and accuracy of the credentialing and payor enrollment processes for healthcare providers. As a centralized repository for healthcare provider information, CAQH offers a platform for providers to submit and maintain their credentialing data in a standardized format
The length of time it takes to complete a CAQH all depends on if the provider has all the required documents and important dates to complete each section. Providers should view the completion and maintenance of their CAQH profile as an essential step in facilitating smooth interactions with insurance companies and other entities involved in the credentialing process.
No. When healthcare providers go through the credentialing and enrollment process, they often have the ability to select the insurance panels or networks they want to join. This allows them to tailor their practice to specific patient populations or demographics and align their services with the types of insurance plans they accept.
No.
The timeframe of 90-120 days is a common estimate for completing the credentialing and enrollment process with insurance panels. Several factors contribute to this timeline:
Accessibility of Information: The availability and accessibility of accurate information, both from the provider and external sources, play a significant role. Delays can occur if there are challenges in obtaining necessary verification from licensing boards, educational institutions, or other relevant entities.
Errors or Inaccuracy of Information: Ensuring that all submitted information is accurate and error-free is crucial. Any discrepancies or inaccuracies can lead to additional verification steps and prolong the credentialing process.
Provider Document Collection: As you mentioned, the speed at which providers submit the required documentation also affects the overall timeline. Providers who promptly gather and submit all necessary documents can expedite the process.
Verification Procedures: Each insurance panel may have its own internal processes for verifying credentials. Some panels may require additional documentation or conduct more thorough checks, contributing to variability in the time taken for credentialing.
Communication and Coordination: Effective communication between the healthcare provider, credentialing organizations, and insurance panels is essential. Delays can occur if there are communication breakdowns or if additional information is requested.
No.
In areas or specialties where there is a high concentration of providers, insurance panels may reach a point where they consider the network to be saturated. In such cases, they may close the panel to new providers to maintain network adequacy and prevent oversaturation.
By staying informed about the requirements and preferences of insurance panels, healthcare providers can strategically position themselves for credentialing success. Understanding the dynamics of the local healthcare market and tailoring qualifications to meet specific needs can enhance the provider's chances of acceptance into desired insurance networks.
NPPES is the National Plan and Provider and Enumeration System. This is the system that generates your NPI. Information here must be updated for verification and validation purposes. For continuity of care you should list a direct address to promote interoperability and Health Information Exchange (HIE).
Yes. We provide medical billing utilizing the EHR platform that you are signed up with at the time our contractual agreement.
We have vendor partnership with Kareo EHR and Claims MD
Yes.
Recredentialing can be required every 3 to 5 years depending on the payor.
Yes.
Credentialing is all about verifiying your credentials and contracting is about the agreement with you and authorized representative approving you a participating provider.
No.
No.
Board Certification looks good on paper but it is not required.
It is recommended that you accept payments via Zelle and Paypal. You can also utilize the EHR system that has a payment collection system.
Yes.
We utilize Intivia Health Medical Credentialing software to manage all information provided by the providers.
No. You must be in contract prior to submitting a claims.
It can take up to 30 days.
It can take more than 30 days if the claims is not completed accurately and efficientlyh.
It can take up to 30 days.
This all depend on revisioins requested, information submitted and color schematic.
No. You are not required to have malpractice insurance in place prior to submitting an individual enrollment
No. Medicare applications are the same nationwide but may have a different Medicare Contractor. Medicaid enrollment process is not the same for every state. Some states can take 15 days to process a FFS (Fee For Service) application or up to 120 days. For nationwide commercial plans like Aetna, Cigna, United HealthCare, etc, you will need to update demographics and provide supportive documentation. It is very important to know that you can not just be simply practice telehealth across state lines without having the appropriate credentials and meeting the licensing requirements. Some will require that you have a place of service for those patients that want face to face service.
You can only have one primary specialty within the CAQH that will recognized as your primary. So if you the insurance application has a direct interface with the CAQH where it pulls in the information automatically. The primary specialty listed is the one that will be recognized.
You are not doing anything wrong. Availity validates your information based on what is listed on your NPI registry. If your information has not been updated in years it may pose an issue when attempting to create an Availity account.
If you are a healthcare provider seeking credentialing services, it's recommended to inquire about the specific fees associated with the process by contacting us via email at preferredchoicecredentialing@gmail.com or zmabillingllc@gmail.com
Although we have a standard price for medical billing, we provide that information at the time of consultation.
Feel free to contact us directly via email at preferredchoicecredentialing@gmail.com or zmabillingllc@gmail.com
Send an inquiry online at preferredchoicecredentialing.com or zmabilling.com
Call us at (347) 569-5995
Yes, we have clients in the following states and growing: South Carolina, Georgia, Florida, New York, New Jersey, California, Texas, Maryland,