Provider Credentialing FAQ’s

What is payer enrollment, credentialing, and contracting?

Payer enrollment is an integral part of revenue cycle management and it includes the steps for a provider to join a specific insurance network. Payer enrollment includes two key processes of credentialing and contracting, which could vary based on the payer.

Credentialing is when a provider submits a participation request to the payer they would like to be in-network with. Once the application is submitted, the player performs a thorough credentials verification process to ensure that the provider meets the credentialing requirements. When the credentials verification i.e. primary source verification is complete, the credentialing file goes to the credentialing committee for approval. Once approved, the contracting process begins.

Contracting is when a provider has been approved by the credentialing committee and is extended a contract for participation in the network. The provider then reviews the contract received, including legal language, terms, reimbursement rates, and other responsibilities of participation. If the provider is satisfied with the contract, then they sign the agreement, and an effective date is received with a provider number. The provider can then begin billing that payer and receive in-network reimbursements for their claims.

How long does it take to get enrolled?

The entire process can take anywhere from 120 to 150 days to fully complete enrollment. Once TriumpHealth gathers the necessary information and completes the applications for all payers, the applications are submitted to the payer. Each payer committee reviews applications once per month and this date differs based on payer.

What can I do to speed up the process?

There are a number of steps that can be taken by a provider to ensure that the credentialing process goes as smoothly and as quickly as possible. One of the most important things is to have all the documentation needed to file the application gathered and readily available ahead of time. Secondly, most commercial payer enrollment will take 120-150 days to complete, so do not wait until the last minute. Be sure to plan ahead if you know your desired billing date so that you can meet your goals.

Additionally, it is helpful to have your CAQH account current, so that payers can utilize the correct information without having to ask for document updates, which will delay the process. Also, it is very beneficial to know the key payers that you would like to be enrolled with. TriumpHealth can help you find the payers that would be beneficial to you as a provider, but the enrollment process can begin much faster if you already have a list of payers in mind.

What is CAQH?

CAQH (Council for Affordable Quality Healthcare) ProView is an online database for storing provider information such as specialty, DEA, license, education, malpractice, CV, and legal records. It eliminates duplicate paperwork with healthcare organizations that require your professional and practice information for claims administration, credentialing, directory services, and more. Most payers require updated CAQH databases for each of their applicants to effectively access and verify their personal information during the enrollment and contracting process. Due to this requirement, a complete and current CAQH is necessary to begin the credentialing process.

How do I participate with CAQH?

In order to create an online profile, you need a CAQH ID, username, and password for the CAQH website. With the Proview system implemented by CAQH, it is required that you contact CAQH directly to acquire a user account. TriumpHealth can handle each step of this process for you and make sure that your account is created, updated, and stays current.

What documents are required by insurance companies (payers)?

The documents required may vary based on the type of provider and insurance company. Here is a list of basic documents that may be needed:

  • Practitioner License(s)
  • Malpractice Insurance (Certificate of Insurance)
  • DEA and State CDS Certificates
  • Board Certifications
  • Diploma (a copy of the highest level of education)
  • Current CV (showing current employer)
  • IRS form W-9
  • Current Driver’s License

TriumpHealth will ask you for the required documentation for each application, in order to make your experience is as smooth and hassle-free as possible.

What happens if the payer denies my application?

If the payer denies your application, you have two options as a provider; accept the denialand file out-of-network claims, or appeal the denial. In order to appeal the denial, you need to craft a successful appeal that convinces the payer panel that you would be a valuable addition to their network.TriumpHealth can work with you to create an effective appeal for you as a provider.

What will help my appeal to be accepted?

In case your application is denied, a few of the common ways to help your appeal be re-filed and accepted include presenting a case of your unique specialty, and the ability to speak more than one language – which helps you provide services to a wider patient demographics. TriumpHealth can help you identify ways that you can market yourself as a valuable provider so that the payer panel can see the value in accepting you into their network.

Why is a payer panel closed?

Often times, payer panels are closed due to the number of current in-network providers in the area. The number of patients in the geographic area may not be high enough to justify adding another provider into the network.

What is re-attestation, re-credentialing, and re-validation?

Re-attestation, re-credentialing, and re-validation are terms that are often used interchangeably, however, there are slight differences within each.

Re-attestation is the process of updating and validating provider’s personal information. This could be required for CAQH and individual payers.

Re-credentialing is often when a specific payer requests a provider to re-enroll with their panel. Providers are asked if they are still seeing patients with that specific payer and are required to confirm that they would like to stay in-network with the payer. Re-validation involves government payers, though some private and commercial payers call their re-credentialing process re-validation as well. This is also used to confirm that a provider is still seeing patients with that payer and that they would like to continue being in-network with the payer.

For government payers, there are deadlines that have to be met in order to complete the revalidation process. If a provider does not complete this process before the deadline, then they will have to completely re-apply to the insurance which can take up to 150 days.

How do I track the status of my credentialing application?

TriumpHealth utilizes a HIPAA compliant software portal where you can log in to view your credentialing status and action items. You can view the status of each application in real-time and have access to all correspondence between our credentialing staff and the payers. TriumpHealth credentialing specialist(s) may request documentation from you for your applications if needed, and these notifications are found within the aforementioned portal as well. Our onboarding team walks you through how to navigate our secure portal during your onboarding process. This helps explain exactly where to go to find any information that you would like to review in real-time, 24×7.

What types of providers can be credentialed?

TriumpHealth assists in the credentialing of the following provider/facility types (may vary depending on the specialty):

  • Doctors of Medicine (MD)
  • Doctors of Osteopathic Medicine (DO)
  • Dentists
  • Oral Surgeons
  • Podiatrists
  • Optometrists
  • Radiologists
  • Hospitalists
  • Physician Assistants (Considered Mid-Level Practitioner) – depending on state laws, may need a supervising or collaborative provider
  • Nurse Practitioners (Considered Mid-Level Practitioner) – depending on state laws, may need a supervising or collaborative provider
  • Clinical Nurse Specialists (NP with specialty credentials)
  • Licensed Clinical Social Workers (LCSWs)
  • Physical Therapists – must have DPT in the clinic for billing purposes
  • Occupational Therapists – must have DOT in the clinic for billing purposes
  • Speech-Language Pathologists – must have DSLP in the clinic for billing purposes
  • Clinical Psychologists
  • Medical Facilities
  • Durable Medical Equipment Companies – must meet guidelines for payer reimbursements

Why choose TriumpHealth?

We ensure that your office obtains its credentials accurately and on time so that you can begin receiving reimbursement from payers of your choice as soon as possible. Our team analyzes the demographics around your practice location and shortlists the most beneficial payers based on subscriber density, enabling you to make an informed decision for what works best for your practice.

We track all applications submitted and maintain accurate records. We contact you regularly to update you on your application status until the process is completed. Our consistent follow-up approach with payers ensures that the payer timelines are met and that your credentials are obtained in a timely manner.

We guarantee complete security, confidentiality, and accuracy of your data, and by trusting us, you can avoid common credentialing pitfalls that lead to denials and underpayments. Our process is one of complete transparency with the utilization of our HIPAA compliant portal, and you are provided with real-time access to any and all updates for your credentialing at your convenience 24×7. We make the credentialing process as easy as possible for you so you can focus on providing high-quality care to your patients.