Health Plans

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.