Credentialing in Medical Billing: Provider Enrolment and Credentialing Services

03 May 2023
credentialing in medical billing

What is Credentialing in Medical Billing?

It is imperative for credentialing in medical billing, which is a crucial process that is required to be performed by all the healthcare service providers for getting enlisted with the insurance companies. The healthcare providers get appended by exclusively credible, evaluated, and validated insurance companies. The healthcare provider becomes a part of the insurer's network of the various medical centres or clinics, health centres, care providers, and hospitals once credentialing in medical billing gets completed successfully. The healthcare operator can receive reimbursements from the insurer when they successfully register and obtain credentials as a listed service provider.

Role of Credentialing Services:

Recently, the insurance team has been swiftly overburdened and decelerated for welcoming new healthcare providers. The reason behind it is that numerous medical practitioners are presently operating actively. At this point, the best thing to do is wisely opt for expert credentialing services and get relief to a great extent from the tedious and time-consuming process of medical credentialing. Doing so gives them enough free time to focus on the patients' needs and render them medical care efficiently. Also, they benefit by remaining successful and driving healthy revenues despite the prevailing competition.

What is Provider Credentialing?

One of the most crucial steps in the revenue cycle is the vital process of acquiring a physician or a provider to get affiliated with the payer, referred to as provider credentialing. With this process's help, the providers benefit significantly by receiving reimbursements for their medical services. Also, the patient can utilize insurance cards to make payments for medical assistance they receive. Hence, healthcare providers must ensure they are enrolled and credentialed with as many payers as possible. The patients can use their insurance plans in their medical practice. But getting registered and credentialed will prevent the patient from searching for other competing providers possessing the same and subscribed to their insurance companies.

Getting the provider credentialed with a payer is a challenging task. It consists of much manual work, such as filling in the application forms, clarifying questions raised by the payers, and consistently following up with them to finish the credentialing request.

What are the steps involved in Provider Credentialing?

1. Assessment of the Application –Assessing the necessary documentation and pointing out if there are any exceptions.

2. Verify the Primary Source Documentation–Substantiate the physicians' informationabout the practitioner/facility.

3. Outbound Call Center –To collect all the missing documents instantly and update the payer's database.

4. Prompt follow-up with Payers –The credentialing requests which got submitted require to be promptly followed up.

5. Recording the Data –The Payer's database must be captured with all the data, labels, and images to get linked to the specific providers/facilities.

6. Data of Provider to be maintained– According to the policies and procedures and CAHQ profile, the provider information needs to be updated.

What are Provider Enrollment Services?

Upon ensuring that the payers hold all the necessary data required to process the claims for all the medical services rendered, the practices enroll for the various services they provide through Provider Enrollment Services. Not just that, these provider enrollment services consistently keep tracking the payers to ensure that the received applications are promptly processed. Even before the provider reimbursements get knocked intensely by the possible administrative issues, the provider enrollment services diligently identify and address them instantly.

What are the steps involved in the process of Provider Enrollment Services?

1. Provider information Validation –To ensure the provider information is accurate, you need to contact the payers to examine the same before submitting the claims.

2. Update the Practice's Billing Address –Proper verification and timely update of the provider's billing or pay-to address.

3. Getting the providers enrolled for electronic transactions –There are four kinds of electronic transactions: Electronic Data Interchange (EDI), Electronic Fund Transfer (EFT), Electronic Remittance Advice (ERA), and CSI. Getting the providers enrolled for these electronic transactions.

4. Keep proper track of the process –An expertly trained and proficient team researches and analyzes the potential processor functionality gaps.

What is Medicare Provider Enrollment?

To get paid for offering the covered medical services for Medicare patients, Medicare providers need to get enrolled in the Medicare program. First and foremost, obtaining an NPI, which could get applied through an online application or paper application, or bulk enumeration, is necessary for Medicare provider enrollment. Once you receive an NPI, you can complete a proper Medicare enrollment application. Following this, you ought to determine whether you are eligible to order or certify before the Medicare enrollment application is submitted. Next, respond to any requests seeking further information within 30 days. Finally, utilize Provider Enrollment, Chain, and Ownership System (PECOS) to ensure and maintain the current enrollment information.

Key benefits of Provider Credentialing and Enrollment Services:

1. Payments get processed more quickly, and you get additional patient referrals.

2. Maintain your updated data with the payers.

3. Keep away from a heap of paperwork and getting exasperated from filling in the application forms.

4. Alleviate revenue leaks.

5. Minimize your rate of denials and stay ahead by recognizing the provider trends.

6. Build and maintain relationships with various payers.

7. Obtain real-time status of the multiple transactions for credentialing and enrollment.


Contact Business Integrity Services to know further about our Provider Credentialing and Enrollment Services. Allow us to guide you, relieve you from this nerve-racking process, and help you remain focused on the patient to provide quality medical care seamlessly.

Choose BIS for a hassle-free payment posting process to enhance your RCM

Business Integrity Services has decades of experience and an excellent professional team who are well updated with emerging new trends and technologies. Hence we gladly offer our expert medical billing and coding services for your organization and aid in staying more focused on rendering quality patient care and thriving in your business, amplifying your revenue.