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Credentialing Process & Key Milestones

14 Oct

Credentialing Process & Key Milestones

Credentialing Process & Key Milestones

Becoming a credentialed provider is a lengthy and complicated process and the timeline to get credentialed can differ from payer to payer. When sending applications to become an in-network provider with a payer, it is important to remember that as fast as you or a hired consultant applies and submits the necessary paperwork, there are internal payer processes that must take place to credential you properly in their systems and make you available and visible to the covered patients. It is also good to keep in mind that governmental insurance plans like Medicare, Medicaid & CHIP have a more tedious process than commercial and private insurances like Blue Cross Blue Shield, Cigna & United Healthcare. This is due to the extra liability that governmental plans have regarding its patients. The verification of each provider and practice is thorough and extensive, to ensure that each provider who is allowed into the payer network is compliant.

Below are the steps and average timeline taken by insurance companies to completely credential a provider into their network.

Send a Provider Interest Form

  • Should receive a response within 10-15 days saying that the payer is or is not accepting new providers into their network in that region

Send Application

  • Normally the credentialing panel meets once per month, and this frequency could be once per quarter, depending on the payer. The day the panel meets also differs from payer to payer
  • If all documents needed for the application are not present or not submitted before the panel meeting date, the application may be pushed to the following meeting date
  • If everything is filed and submitted correctly, normally the payer will acknowledge receipt of application-in-process within 30-45 days

Application Accepted

  • If the application is accepted, the payer may give a preliminary provider agreement and/or a proposed contract with reimbursement rates, for providers review and approval

The internal payer filing process begins

  • Once the provider signs and the contract is fully executed, the payer files and sends provider information to all advantage plans associated with that payer
  • The payer alerts customer service so that when the patients call, the provider is recognized as an in-network provider for covered services

The entire credentialing process may take anywhere from 120-150 days for a provider to be in-network

Please bear in mind that even when the provider is in-network with an activation date, it may take anywhere from one week up to 90 days for the provider contract to be loaded into the payer system

If you are facing any of the following credentialing challenges:

  • Too much credentialing paperwork or simply don’t have enough time in the day
  • Inaccuracies in payer applications or issues with auditing of credentialing paperwork
  • Struggling to keep track of payer applications
  • Setting up a new practice
  • Adding new providers to your practice or organization
  • Opening up a new location or changing locations
  • Losing revenue due to credentialing denials

Please feel free to contact us today, so that an experienced TriumpHealth credentialing specialist can provide you with an expert advice and dedicated support. We are here to help you navigate the credentialing process and maximize revenue.