Credentialing

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Credentialing is the process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy. Many health care institutions and provider networks conduct their own credentialing, generally through a credentialing specialist or electronic service, with review by a credentialing committee. It may include granting and reviewing specific clinical privileges, and allied health staff membership.

Insurance Credentialing[edit]

Insurance Credentialing (Provider Credentialing or "Getting on Insurance Panels") is the process of becoming affiliated with insurance companies so that you (the provider) can accept third party reimbursement.

While just a few years ago health professionals considered insurance credentialing “optional” for building a practice, today it has become more necessary than ever for providers to be networked with insurance companies. In part, this is because more persons/patients in the US have health insurance than ever before, and because patients desire (even demand) to use their health insurance when seeking out health care services (in lieu of out-of-pocket payment).[1]

In addition, insurance credentialing is becoming more important as health insurance plans are becoming broader in regards to the scope of treatments that they cover. These changes include Mental Health / Behavioral Health parity, less restrictions on pre-existing conditions, and the coverage of supplemental services such as physical therapy, massage therapy, acupuncture, and other holistic health services.[2]

The majority of the insurance panels will allow you to apply for insurance credentialing right after you received your license. But there are a few that want a year, two years, or even three years. There are different regulations for each state. Some will require two years, and BCBS in GA, for example, only requires two years.

But there are ways to get credentialed sooner. Usually you can get credentialed if you are past one year of holding your license. Since a lot of the credentialing process is regulated by the state, even with national insurance companies, the state has much to do with the process to apply.

What does the Affordable Health Care Act hold in store for credentialing?

2013 is going to be a transition period. It is going to be a time for insurance companies to start putting into place the changes for 2014. There should be less availability within the insurance panels. Because more people will have insurance, there will be a need to have more providers credentialed. The more members you have, the more providers you are going to need.[3]

There may be a few different challenges as the year progresses and more insurance companies are formed.

2014 is the year that all of the changes will take place. For those living in urban areas where the panels are shut down for now, 2014 should open up the major panels, but it also may open up some new insurance companies.

Personnel Credentialing[edit]

Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment). Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.

Political Credentialing[edit]

Political parties credential delegates at their conventions.

Paperless Credentialing[edit]

Paperless credentialing is the process of doing credentialing through a software package. With the internet, many web-based programs have been created to help automate the process of paperless credentialing.

Medical Credentialing[edit]

Medical Credentialing is the process of review and verification of the information of a health care provider who is interested in participating with Various Insurances in their County.[4]

See also[edit]

  1. ^ Centore, Anthony. "Insurance Credentialing". Thriveworks. Retrieved 6 February 2013. 
  2. ^ Centore, Anthony. "What is Provider Credentialing?". Thriveworks. Retrieved 25 March 2013. 
  3. ^ Centore, Anthony. "Credentialing and the Affordable Health Care Act". Thriveworks.com. 
  4. ^ "Credentialing Services". ClinicSpectrum.com.