CREDENTIALING
What is Medical Credentialing?
Medical credentialing is a process used to evaluate the qualifications and practice history of a doctor to establish competency. This process includes a review of a doctor’s completed education, training, residency, and licenses. It also includes any certifications issued by a board in the doctor’s area of specialty. Hospitals, insurance providers, Medicare and Medicaid conduct medical credentialing to determine which physicians meet their requirements prior to permitting them to practice in their network. These entities continue to do so, on a regular basis as dictated by states, regulatory bodies and accrediting organizations. While this may seem like a simple, straight-forward process, each hospital and third-party agency requires their own specific type of medical credentialing processes, forms, rules and requirements. Therefore, it is imperative to know the specifics of each hospital or agency in order to save time, money, and headaches.
Getting Credentialed
As you can see, credentialing is an arduous process, especially since each entity has its own requirements. Click each category below to find out more information.
INFORMATION FOR NEW PHYSICIANS
Starting a new practice is challenging enough, so why not lay a solid foundation for success by ensuring all of your credentials are complete and compliant with Nationwide Credentialing? We obtain, negotiate and complete all credentialing applications to hospitals, health plans, Medicare and Medicaid. All you have to do is review the documents and sign! Once submitted, we will track each set of documents through completion. Following credential setup, we will work with your practice to ensure that all future credentialing and contracting needs are handled and fulfilled.
By allowing Nationwide Credentialing to fulfill your credentialing and managed care contracting needs, you reduce your initial overhead by abolishing the need to hire and train someone to handle the hassles and continued follow up required with credentials and managed care paperwork.
Before a physician can provide patient care in a hospital facility, the hospital must first grant privileges to the physician. Securing these privileges should be the first step in the credentialing process, as they serve as a pre-requisite for health plan credentialing. Health plans require that physicians have privileges at participating network hospitals or they will not be able to join.
Prior to granting privileges, hospitals will verify a physician’s training, education, and practice expertise based on the rules set forth by the Joint Commission on Accreditation of Healthcare Organizations. This also includes a physician’s references, claim history, case and procedural logs, and much more. Upon completion, the hospital’s credential committee reviews the information and if approved sends it on to hospital’s executive committee and board of directors for the final seal of approval. Once approved, the Hospital Committee appoints the physician to the medical staff for an initial period of one year, and two years upon each renewal thereafter.
The standards for approving a physician’s credentials varies by insurer. The National Commission for Quality Assurance (NCQA) sets the standards for which physician credential approval is based. Like hospitals, the NCQA requires primary source verification of a number of credentials, including: education, training, licenses, board certifications, work history, insurance coverage, and malpractice claims history. However, meeting these requirements is only the first step in joining a health plan’s network. Once this initial hurdle is overcome, each health plan will require its own set of information. Some key pieces of information that all plans require prior to starting the process is a physical office location, phone, fax and a physician’s National Provider Identifier (NPI), a 10-digit identifier obtained by the Federal government. Once approved, physician data such as office locations, tax identification numbers, and specialties are added to the health plan’s billing system.
Pitfalls to Avoid:
- If a physician’s data is entered into a health plans billing system incorrectly, claims will go unpaid.
- Health plans link a physician’s board certification status and training to allowable procedural terminology (CPT) payment codes. These codes are provided to each credentialed physician.
- If a physician submits a claim for a code not on their approved list, the health plan will NOT pay the claim. For example, if an oncologist submits CPT codes designated to cardiologists, the claim will be denied. These codes must be correct!
- When you have multiple office locations, each of those addresses must be on file with each health plan. If you send in a claim with an office address that is not in the health plan’s billing system, the claim will either be denied or paid as out-of-network.
Many physicians believe Medicare to be one of the best forms of insurance to accept, as they tend to pay well and expeditiously. However, Medicare also requires the most difficult credentialing process.
Generally, Medicare requires four applications:
- 855B—(Group of more than one physician) Establish or change a practice group number.
- 855I—Establish a physician’s individual number.
- 855R (To link the physician’s individual and group number together)
- 588-Electronic Funds Transfer (EFT)
A 48-page Medicare application that physicians must submit in order to obtain a group number for billing purposes. This form is also used if a practice needs to make changes and/or additions to the physician listings, including: ownership, contact information (i.e., phone number and address), etc.
A 29-page form used to obtain a physician’s Medicare number for billing purposes. This application requires a copy of the physician’s and NPI letter.
An eight-page form linking the individual physician’s Medicare number to the practice’s group number.
This is mandatory, must have an original voided check with all printed information for the group listed.
Pitfalls to Avoid:
- When submitting the 855B form, the name of the practice must match exactly with the name submitted on the practice’s IRS letter, the National Provider Identifier (NPI) letter, and the practice checking account.
- When you have multiple office locations, each of those addresses must be on file with each health plan. If you send in a claim with an office address that is not in the health plan’s billing system, the claim will either be denied or paid as out-of-network.
- In most cases, only authorized or delegated officials may report changes to the practice’s Medicare enrollment record.
- Once a physician’s Medicare number is issued, it must be used within a 12-month period or face deactivation. If deactivated, the 855I form will need to be resubmitted.
