Insurance Carrier Credentialing – Avoiding Some of the Pitfalls

October 27, 2016

Insurance Carrier Credentialing – Avoiding Some of the Pitfalls

Obtaining Insurance Carrier credentialing is an essential part of any practitioner’s preparation to begin work anyplace in the United States. As foreign as it may seem to some, you must have acknowledgement from carriers that they know who you are, where you practice, if you are in a network that accepts assignments, where to send payments and what tax id# to record the payments to for tax purposes. If any information that exists in their files needs to update do to your practice affiliations, addresses or pay to info, you need to re-credential.

The Federal agencies such as Medicare and Medicaid have specific paperwork that must be completed.

Others require an HCAS form (HealthCare Administrative Solutions) which gives them pertinent information and requests your CAQH # (Council for Affordable Healthcare) to verify all information given the carriers. This is done by having the provider attest to the information yearly. There are over One million clinicians identified in CAQH for the carriers to research and verify. Many carriers who have networks require an initial letter of intent to screen your specialty in the requested practice area and will let you know if they do not want additional practitioners in that specialty for that geography.

Always best to know this before deciding to initiate a new practice or even join an existing one.

The Blues all have their own forms, depending on the state where you will practice.

This process of credentialing can, and in most cases is, long and arduous. I recommend hiring a specialist familiar with your area who knows the idiosyncrasies of the carriers you will be billing. The benefit will far outweigh the cost in the long run.

In many instances, the carrier will reach out for additional information or clarification of what you sent and it is time sensitive. If not picked up in an email that goes to junk mail, or put on someone’s desk who does not realize its importance, you may have to start the entire process with that carrier from the beginning, losing more and more time before you can see patients with that particular insurance.

Carriers do not back date applications and will only approve from the date the paperwork is received.

If you are just starting out, be sure you have hospital privileges (if applicable), a State license, a DEA#, NPI#, CAQH#, TAX id# (if not reporting to your social security #). If joining a group that participates in a PHO (provider health organization) or any other type of hospital affiliated group, that you reach out to the person who credentials for the Health Maintenance Organization’s that negotiate fees with that hospital and PHO. That is the only person who can obtain your contracts for those carriers.