What Is the Process of Getting Credentialed with Medical Insurance Companies?

The process of getting credentialed with medical insurance companies is also known as provider enrollment and is the first step of the process for inclusion into payment panels. While the process can be time-intensive, provider enrollment is the only way a healthcare provider organization can become an in-network provider and be paid by insurance companies.

Although enrollment requirements differ among payers, these steps will get you started. Don’t sleep on the process; getting enrolled and credentialed with an insurance company can take anywhere from 90 to 150 days. Missteps or postponement can cause cash flow delays and scheduling issues for your healthcare organization.

The first step to provider enrollment is credentialing. Here are the steps to keep in mind when undergoing credentialing:

1. Be prepared: You should have your NPI number readily available and be fully licensed and in good standing in the state in which you intend to provide services.
2. Submit a participation request to the health plan using their application process: “Join network” should be a button or link on your insurance company’s website.
3. Panel determination: Once the health plan receives your application, they will perform a credentials verification across a multitude of databases using Primary Source Verifications. Once verification is complete, their credentialing file will go to the Credentialing Committee for approval. During these phases, you should receive a reference number to check your enrollment status. Often this is the most time-sensitive piece of the process as your credentials must be screened and verified against a multitude of federal and state databases. If the provider’s credentials are expired or ineligible, it will take longer.

Once the Credentialing Process Is Complete

Once the credentialing process is complete, the second step of provider enrollment is contracting with the insurance networks. The contracting process is the agreement that you will make with insurance companies. Contracting is separate from credentialing and is drafted by a contracting representative with whom you will review the language of the contract, discuss reimbursement rates, and all the details and responsibilities of participation. Your agreement will be mailed to you for review and a signature. It is critical to thoroughly review the fee schedule. If the fee schedule is not included in your agreement, you may request it.

Once your contract is signed and returned to the payer, you will be designated an effective date and provider number in your letter of participation. After you receive your letter of participation, your organization should ensure that the billing system is updated to begin receiving claim reimbursement. This part of the process may take 30-45 days, so the faster you update your billing system, the quicker your healthcare organization will be reimbursed.

The In-Network Billing Process 

Once your organization is enrolled in-network, your healthcare organization should establish a process for billing your health plan for services. By establishing a routine process, your organization can avoid costly delays.

Streamline collections by:

1. Verifying patients’ insurance information before they come into the office
2. Make sure that the payment is eligible for the service provided
3. Collect copayment. Routine copays cannot be waived as per the Anti-Kickback Statute and False Claims Act.
4. Submit claims in a timely manner
5. Bill secondary payers in a timely manner
6. Analyze and recognize patterns in denials to identify errors

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