Credentialing

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Credentialing is the process of establishing the qualifications of licensed medical professionals 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 / Medical Credentialing[edit]

Physicians and other healthcare providers including hospitals and facilities who wish to bill an insurance company and receive reimbursement for services as an in-network provider must undergo a process of credentialing. This process is called medical credentialing or insurance credentialing. Both medical credentialing or insurance credentialing or provider enrollment are used interchangeably. During this process, insurance companies verify the provider's education, training, experience, and competency. In order to start this process, the provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty. While large hospitals and health systems use their own credentialing team to perform this most group practices and solo practitioners use credentialing companies to complete the paperwork which is quite complex at times. Once the verification is complete, the insurance company then decides if the provider meets their internal qualifications to serve as a provider of services to their insured members. After approval of a provider's credentialing file, the insurance company then issues a participating provider contract that allows the provider of services to bill the insurance company and receive reimbursement as an in-network provider of services. Failure to complete the insurance credentialing process will result in the provider being paid as out-of-network for services rendered. There is more out of pocket costs involved with out of network providers so more and more physicians get in to network with insurance companies. Insurance credentialing typically takes 2-4 months depending on the payor.

Typically credentialing is needed for the following providers

  • Physicians MDs, DOs
  • Dentists
  • Physical Therapists,
  • Speech Therapists
  • Psychology Counselors
  • Occupational Therapists
  • LMFT
  • Group Medical Practices
  • Clinics
  • Hospitals
  • DME Companies
  • Home health agencies

Most providers who see medicare and medicaid patients must be credentialed to get paid for the services rendered. Some state medicaid have MCOs (managed care organizations) where providers have to be credentialed with medicaid before getting credentialed with MCOs.

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.

See also[edit]

References[edit]