Credentialing FAQ’s
What does Credentialing mean?
Credentialing is the process of verifying the qualifications and legitimacy of licensed medical professionals in the healthcare industry. It involves assessing an individual’s knowledge, skill, or performance level to grant a designation, such as a certificate or license. The process includes verifying information such as education and training, residency, licenses, specialty certificates, qualifications, and career history through a process known as primary source verification (PSV). PSV involves reaching out to the original source to verify that the information is accurate as represented by the applicant. In addition to credentialing, a provider may also need to go through payor enrollment.
What is provider enrollment?
Provider enrollment is the process of registering with a health insurance network to become an in-network provider. It allows you to treat patients who carry that insurance and be reimbursed for your services. The process of provider enrollment varies depending on the insurance company and the type of provider. For example, if you are a Medicare provider, you can enroll online using the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). You will need to register for a user account if you are an individual practitioner, authorized or delegated official for a provider or supplier organization, or an individual who works on behalf of providers or suppliers. Once you have registered, you can securely and electronically submit and manage your Medicare enrollment information. If you are not a Medicare provider, we will contact the insurance companies on your behalf, directly to submit you to their provider enrollment process.
Do I need to submit my applications? What if I was already enrolled with insurance companies with my previous employer.
No. When you establish a relationship with SWC, we will submit these enrollments for you. We enroll each clinician with about 7-9 payors, sometimes up to 10-15 payors, depending on how many state licenses you have and which states. We also determine the payers by the business demand and patient population. If you were previously enrolled with other employers, we do not terminate any network participation you are currently enrolled with. Most of the time, it is just a matter of adding your new practice demographics to your profile. It helps if we know which plans you are enrolled with. The typical payer list is: Aetna, Cigna, Magellan, Tricare, United Healthcare, Humana, Value Options/Beacon Health Options, Medicare, Medicaid, BCBS and many others.
Why would I want to get credentialed? I receive my pay from LunaJoy.
Being credentialed with insurance panels means that you are able to see patients who have specific insurance plans and we bill those insurance companies directly for the services you render. This can greatly increase the number of patients who you can see.
How long does the credentialing process take?
Typical turnaround time is 45-120 days. It is very important to always keep your information up to date, such as licenses, CV (resume), CAQH, PECOs, NPPES, and your personal demographics. This can help avoid delays. Until then, don’t worry. You will be able to see patients in the interim.
What do I need to get credentialed?
Please provide your NPI, PECOs, CAQH and NPPES login information. If you do not have that information, please contact former or previous affiliates to assist or click the links below to complete and account recovery. If you need assistance, we are more than happy to help.
https://pecos.cms.hhs.gov/pecos/login.do
What is CAQH?
CAQH stands for Council of Affordable and Quality Healthcare. It is a nonprofit that was created several years ago by the private insurance panels. Most commercial payers require that you have the CAQH profile completed before you begin the credentialing process. Panels use the CAQH to verify providers personal information as well as education and work history. The information on your CAQH profile must be up to date and we will add Thriving Lane’s information. This must match your current CV.
How do I obtain a CAQH ID number?
Almost all insurance panels will require providers to have or obtain a CAQH ID. If you don’t already have one, we are able to create one for you! Let your specialist know that you’d like to have us complete an application for you and we’d be happy to add it to your project. Otherwise, please visit CAQH ProView to start the process.
Once I’m approved, what are the next steps?
Since you are joining our group and we already participate with insurance companies under a group contract, you’ll be added to the group contract.
Why do I have to complete recredentialing?
If recredentialing is not completed, you may not be eligible to continue to participate in the UnitedHealthcare network. Recredentialing is required at least every 2 years by the NCQA, CMS and many state regulatory organizations. Recredentialing helps make sure that all health plans have the most up-to-date, accurate information about your education and experience. It also allows you to review the practice locations and contact information we use in provider directories that we make available to all members.
Why do I have to get my own liability insurance?
You should have professional liability insurance if you provide services to clients for a fee. It protects your business against claims of mistakes or professional negligence, even if they’re unsubstantiated.
What professional liability limits are required?
State regulatory bodies require a minimum of $1,000,000 per occurrence / $3,000,000 in aggregate. If I have questions regarding the medical staff categories, who should I contact?
Please contact our a credentialing specialist at info@esteemconsultingservices.com
If I am in private practice, do I need to complete the work history sections?
Yes, we ask you to please complete all work history on your CV and in CAQH.
List of Typical Documents expected for your complete credentialing file:
• State(s) Professional License
• Federal Narcotics License (DEA Registration for each state you prescribe in)
• Curriculum Vitae with a complete professional history in chronological order
o (Your application will be compared to your CV if discrepancies are noted your application will be delayed.) Please review your application before sending it in. Make sure it is readable and in black ink.
• MD/DO’s: Diplomas and/or certificates of completion (e.g. medical school, internship, residency, fellowship, case logs etc.)
• For PA’s, APRN’s, PMHNP’s: We will need a transcript & case logs from your professional degree NP or PA sent directly from the educational facility to us.
o Diplomas and/or certificates of completion in masters level program
o Nurse Protocol Agreement or the Delegation of Services Agreement between the PA and the supervising physician.
• Diploma of National Board of Medical Examiners or Educational Commission for Foreign Medical Graduates (ECFMG) Certificate (if applicable)
• Specialty/Subspecialty Board Certification or letter form Board(s) stating your status (if applicable)
• Declaration Page (Face Sheet) of Professional Liability Policy or Certificate of Insurance COI. Must add Thriving Lane to COI for each state.
• Permanent Resident Card or Visa Status (if applicable)
• Military Discharge Record (Form DD-214) (if applicable)
• Continuing Medical Education (Please list on the Explanation Form(s) all postgraduate activities and scientific meetings that you have attended or for which you have received Category I credit in the past twenty-four months or provide copies of certificates.)
• Current government or state-issued photo ID. (driver’s License, Passport, etc.)
• Current NRP, PALS, BLS, and ACLS Card if applicable.
• Copies of any licenses from other states
• 3 Peer References. Professional References - all need to be in the same professional discipline. I will also need their emails. Ex. For a PA, need references to be 2 PA’s and 1 MD. On the application, please be sure to list the address, phone #, fax #, and e-mail for each of your three references. These should be actual peer references and practicing in the same field as you.
• W9
• Explanations of any disciplinary action, in writing, including what happened and the outcome
• Please use the Explanation Sheet for any explanations of your application