Physician credentialing is one of the key processes in healthcare. To bill any service to the insurance payer, the physician and the organization should be credentialed by the payer. In simple terms, they should enrol in the payer’s network and get authorized to render services to the patients who have enrolled with the payer’s insurance schemes.
Physician credentialing is the process of validating the provider’s professional records including qualifications, experience, certifications, license, and other records. Credentialing is not a one-time process in the doctor’s practice. Credentialing happens in the following scenarios.
• Initial credentialing when a physician or a healthcare provider joins or starts a new practice
• When a physician moves from one practice group to another
• When a physician joins new practice groups
• When a physician or a health care provider enrols with a new insurance payer
• Recredentialing to maintain their credentials
With an exhaustive list of information to be collected, submitted, and verified, Credentialing is a tedious and a lengthy process and may usually take about 2-4 months to get credentialed. Sometimes, it may even take 6 months when documentations are not done completely, and the file goes back and forth as well as processing delays from insurance end.
Earlier, every provider must individually get credentialed with every insurance payer by submitting all the required documents. It is still the same for some of the cases. However, many of the insurance companies are now using a centralized database. One of the most used web databases for credentialing is The Center for Affordable Quality Healthcare, Inc. (CAQH). CAQH’s online database is the Universal Provider Database (UPD). It gathers and collates all information that are necessary for credentialing and provides it to payers.
Physician Credentialing process Checklist
To add healthcare providers at a newly established practice
This step-by-step process checklist will guide you in the process of starting a new practice and ensuring that credentialing of all the physicians and providers are done.
- 1. Create a new group in your state and obtain your Tax ID details from the IRS.
- 2. While collecting the information on your EIN, download the e-file (CP-575).
- 3. Fill in the complete address of your medical practice.
- 4. The next step is to apply for a Group NPI.
- 5. Update your attested CAQH profile along with your CAQH ID.
- 6. Next is to identify the insurance payers you want to credential with. This should include all statutory requirements also like Medicare,Worker’s Compensation, Tricare and other commercial PPOs or HMOs and any other insurance carriers and payers you would deal with in your practice.
- 7. Update the billing address and create a W9 form.
- 8. Hospital services would be required for any specialist treatments and services. So, hospital credentialing will be required by insurance carriers to bill those services. So, initiate the credentialing process with the near-by local hospitals. You can also have a covering provider or hospitalist group covered for treatments requiring admissions in hospital.
- 9. Obtain a permanent office phone and fax number for your medical practice. This must be provided in all applications including CAQH.
- 10. Most insurance payers require a malpractice policy document. Hence frame a malpractice policy document and publish the same.
- 11. Insurance companies will be accessing your details through CAQH portal. Ensure you provide required access controls and authorize insurance companies to access your profile details.
- 12. Have your business license, incorporation certificates, liability insurance of the medical practice, worker’s compensation insurance, CLIA certification or waiver if applicable, to apply for Medicaid if required.
- 13. With the above-mentioned details and information in place and completing the steps, you may apply to various insurance payers to avail their services for your practice.
To add a new healthcare provider at a current practice
This step-by-step process checklist will guide you in the process of adding new physicians or healthcare providers your existing medical practice group.
- 1. Update the provider’s CAQH profile with the new practice affiliation mentioning the start date. Attest the same and provide for credentialing.
- 2. Also, update the provider’s license and DEA with the new state if their practice was at a different state earlier.
- 3. Attach the list of payers the new medical group is currently affiliated with, including TPAs, Medicare advantage, Medicaid HMOs, worker’s compensation, Tricare, and other commercials.
- 4. Update the new TAX ID in the provider’s CAQH profile and provide the same to the insurance carriers as well and authorize the appropriate insurances to access the information
- 5. Update the provider’s CAQH profile with the local list of hospitals where they would be associated with. Hospital credentialing is mandatory for certain payers or specialty providers.
- 6. Update the provider’s CAQH profile with the new malpractice policy.
- 7. Obtain and give the medical group’s primary billing type to be filled in the application.
- 8. For Medicare, mention the medical group’s Medicare PTAN that you are looking to be added on. This will be mentioned on your Medicare application which will be linked to the new medical practice.
Documents checklist for physician credentialing
We have prepared this handy check list for quick reference to process any credentialing (includes details required for both medical practice and providers)
- Name (exact name as in records)
- Known by any other names
- Date of Birth
- Citizenship Information (Permanent Resident Card, Green Card or visa status (if applicable)
- e-mail Address
- Mailing Address
- Contact Number
- Recent photograph signed and dated in the margin
- Updated Curriculum Vitae (with complete professional history in chronological order and no gaps, exact beginning, and end dates to be mentioned)
- Social Security Number
- Practice Address
- Practice Tax Id
- Practice Contact Number
- Practice Fax Number
- Business License of the Medical Practice
- Various insurance coverage details of the Medical Practice
- Copy of National Provider Identifier Number (NPI No.)
- CAQH login id and password
- PECOS login id and password
- Medicaid details
- Copy of current Federal DEA
- Copy of current State Controlled Substance Registrations or certificate(s)
- UPON number
- Current CME Documents
- Educational qualification (to include month and year of attendance, institution name and address, program director name, and degrees attained, diploma, training certificates)
- Copy of current Board Certificate, including the name of issuing board and dates of board certification/recertification
- ECFMG certificate number and info on Fifth Pathway, (If you are a foreign graduate)
- Copy of current active state licenses
- All previous, current, and pending hospital affiliations
- Copy of Professional Liability Insurance Coverage (for the past 10 years with complete details)
- Malpractices Policy document
- Any malpractices history, if any, with complete details
- Any disciplinary actions, if any, with detailed explanation
- Military discharge record – Form DD-214, if applicable
- Peer References / Recommendations with assessment of your clinical competence and date and year mentioned
- Completed Delineation of Privileges Form