Being credentialed with insurance panels means that you are able to see patients who have specific insurance plans and bill those insurance companies directly for the services you render. This can greatly increase the number of patients who can access your services.

Together, we decide what insurance companies you want to work with based on your license type and your practice location. Then our staff will begin the process of retrieving, completing, submitting, and following up on applications on your behalf. We keep in touch with you throughout the process and contact you if we ever need any additional information.

Retroactive Billing is an option with certain payers depending on the situation.  It’s primarily used for Medicare and Medicaid when you are opening or starting work before the credentialing is complete.  It allows you to hold the claims and submit to the insurance company once everything is approved.  You need to be sure that you understand how to qualify for retroactive billing as changes each year and it’s not as simple as it used to be.

Primary Source Verification or Provider Credentialing is done by companies that will use the information from CAQH to open the process. During this process, a credentialing specialist verifies all of the information in CAQH or on the application and analyzes it for mismatched information or gaps in information. They determine if accurate information has been provided. Once all the information has been verified, the application works its way through a variety of meetings for approval. Once approved, the application can then be sent to the contracting department for a contract to be created and sent to the provider for signature.

This occurs after a provider has been linked to a Tax ID or a contract has been signed and sent to the payer for counter signature.  This process typically takes 30-45 days to complete.  Once this process is completed, the payer typically issues a letter or an email with the provider’s effective date and provider ID number (if issued).  This is the last step before being able to bill.

Linking happens when a provider is credentialed but does not have an individual contract. They are linked to a Tax ID that does have a contract.  The linking process occurs after credentialing and typically takes around 30-45 days.

The contracting department drafts a contract specific to the specialty and region the provider works in. The provider reviews and signs or reviews and requests modification until the contract is satisfactory to both parties. Medicare and Medicaid have their contract incorporated into the application process. However, Medicaid and Medicare Advantage or managed care plans do need to contact your organization.

EDI (Electronic data interchange) is like the highway between your billing system and the insurance company.  It’s the communication channel by which your billing system communicates claim data to the various payers

CAQH stands for Council of Affordable and Quality Healthcare.  It is a nonprofit that was created several years ago by 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.

ERA or Electronic remittance advice is a digital EOB (explanation of benefits) that shows what the insurance company paid (or didn’t pay) and all the claim details.  Many billing systems can automatically post these ERAs to the patient’s account.

EFT (Electronic Funds Transfer) is the preferred method of payment for many insurance companies and the required form of payment for Medicare. Medicare requires you to complete Form Cms-588 when enrolling in Medicare, which details how you would like to be paid.

A panel is usually the equivalent of an insurance company. The term is commonly used to refer to a panel of plans. This is demonstrative of the fact that when a provider is on a panel he or she can bill for all of the plans under that panel.

The popularity of insurance companies varies depending on location. However, some of the most popular and largest insurance companies are Aetna, Cigna, Magellan, Tricare, United Healthcare, Humana, Value Options/Beacon Health Options, Medicare, and many others.

Demographic updates are slightly different from standard credentialing because they are used to update the information for a provider or organization that is already credentialed.  These changes take around 30 days to complete, depending on the payor and their workload.

Unfortunately, we cannot guarantee that a provider will be accepting into the network as that power lies with the insurance panel. However, if you are not approved for participation, we will either follow through with an appeals process (if the panel has one) or we will wait until the next quarter to submit a new application.

We have credentialed healthcare providers of more types than we can list: from chiropractors to behavioral health providers to surgeons. If you are eligible to be credentialed, we can get you credentialed!

Yes. When you sign up for credentialing with us, you get to choose exactly which panels you want and don’t want, to be credentialed with. Typically most outpatient physician providers credential with 7-8 payors, whereas hospital-based physicians (in-patient) usually credential with 10-15 payors (pretty much any patient with any insurance that comes to hospital). Physicians working in the tri-state area (border of 3 states) like in our physician owner practice credential with 25 payors.

If you are fully licensed, we should have no problem identifying plenty of insurance companies and third-party payers for you to be credentialed with. In some areas, some panels can be very selective or closed. In these instances, we will talk with you about the likelihood of a successful medical credentialing process. We want you to get the most out of your medical credentialing investment, but we cannot guarantee that insurance panels will accept you.