The Difference Between Provider Credentialing and Provider Enrollment

Aug 5, 2021 | Verisys Blog

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Provider credentialing and provider enrollment are necessary for healthcare organizations to receive payment from insurance and government payers. Although the processes are related, they each require several steps which are quite distinct. Provider credentialing is the process by which organizations verify that a provider’s credentials are current and valid. Provider enrollment consists of gathering information to help insurance companies recognize providers’ participation in their network.

9 Steps of Provider Credentialing

Provider credentialing is performed to verify that a provider’s credentials (such as education, work history, and certifications) are complete, current, and valid. This process is required by law to protect patients from harm, fraud, or abuse. Not only is credentialing mandated by federal regulations, it also protects organizations from fines, lawsuits, and other penalties by employing excluded or unscrupulous providers. To perform credentialing properly, an organization should take the following steps:

1) Gather all necessary information. It can be helpful to make a list of the items you’ll need from the provider. These usually include professional licenses, educational information, work history, certifications, references, background checks, malpractice insurance information, W-9 form, practice ownership details, and more.

2) Collect the National Provider Identifier (NPI), Federal Tax ID, and Practice EIN. The Practice EIN, issued by the Internal Revenue Service to identify employers, should match the number on the provider’s W-9.

3) Register the provider with the Council on Affordable Quality Healthcare (CAQH) and make sure the provider’s W-9 information and malpractice certificate are valid. Avoid application rejection by making sure the provider’s resume is formatted correctly, with dates entered as MM/YYYY and no employment gaps. Keep a record of the information. The provider will be required to re-attest the details several times per year.

4) Get the provider’s original handwritten signature if necessary.

5) Complete and submit the applications to each insurance payer.

6) Once you receive a reference number from the insurance payer, keep a record of it.

7) Follow up on the provider’s application status by calling the insurance payer and provide any missing information. Keep a record of all follow-up calls or other communications with the payer.

8) Update your billing system with payer information. Your Medicare Electronic Data Interchange enrollment form (EDI) must be completed before submitting electronic payment claims to Medicare. Review fee schedules with payers.

9) Document all credentialing applications, contracts, communication, and enrollment letters you receive from insurance payers.

The 6 Steps of Provider Enrollment

Provider enrollment is the process of applying for inclusion in an insurer’s provider panel so providers can be paid for their services. It includes several steps as follows:

    • Request enrollment by submitting a participation request.
    • Perform a credentials verification process with primary source verification.
    • Receive credentialing committee approval from the payer.
    • Receive a contract for participation; review the contract for rates, languages, and details of responsibilities.
    • Sign agreement and return it to the network.
    • Receive an effective date from the payer to begin billing and making reimbursement claims.

Performing credentialing and provider enrollment can be time-consuming for healthcare organizations. They require organizations to obtain and keep current records on all their providers and their credentials, maintain communication with primary sources, closely follow new and current healthcare regulations, and monitor the status of all their providers.

CheckMedic® by Verisys streamlines provider and vendor credentials verification using thousands of primary sources with verified and accurate results for every individual in your population. Learn more about how Verisys can help you verify your providers’ credentials so you can save time and simplify provider enrollment.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
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