What documents are needed for insurance credentialing

Document needs vary based on the type of provider and insurance plan.  Here are a list of base documents that may be needed:

Core Documents for an individual:

  1. Practitioner License(s)
  2. Malpractice Insurance (Certificate of Insurance)
  3. DEA (federal) and state CDS certificates
  4. Board Certification(s)
  5. Diploma – copy of highest level of education (required for non-MD’s,DO’s)
  6. Current CV (showing current employer, and all entries have mm/yy format)
  7. IRS Form W-9
  8. Current driver’s license

Other documents that may be applicable:

  1. ECFMG Certificate (if educated outside of The United States)
  2. Passport or other citizenship documents (if born outside U.S. and not previously enrolled in Medicare)
  3. Collaborative Agreement (required for Nurse Practitioners)
  4. Admitting Arrangement letter (required for providers who do not have hospital admitting privileges)
  5. Prescribing arrangement letter for providers not holding DEA certificate

Documents needed for your legal entity:

  1. IRS form CP575 or replacement letter 147C (verification of EIN)
  2. CLIA Certificate
  3. Business License
  4. Copy of office lease (required for therapy facilities)
  5. Letter of bank account verification (for Medicare enrollment)
How long does it take to complete credentialing

Commercial insurance carriers vary widely in their turnaround time of your requests for credentialing and contracting.  Most major carriers can complete the process in 90 – 120 days.  Smaller regional or local plans may take even longer.

When submitting a participation request to a commercial carrier, you will undergo two distinct process.  First is credentialing where the carrier verifies your credentials and presents your credentialing application to their committee for approval.  After you are approved by the carrier’s credentialing committee, you then complete the contracting process to become a participating provider and receive an effective date.

Commercial carriers do not allow for retroactive billing.  Until you have a complete contract and are listed “In-Network” in the carrier claims system then you will not receive in-network reimbursement for your claims.  While billing out of network, your patients will receive a much higher bill for your services and possibly be responsible for 100% of your charges.

How long does it take to enroll with Medicare

Medicare typically completes enrollment applications in 60 – 90 days.  This varies widely by intermediary (by state).  We see some applications turnaround in 15 days and others take as long as 3 months.  Medicare will set the effective date as the date they receive the application.  So, even if it takes 3 months for them to complete an application, you will be able to retroactively bill Medicare for services from the date your application was received.  Furthermore, Medicare allows for a 30 day grace period that allows you to bill for dates of service up to 30 days prior to your effective date.  So, if your application is received on May 1st and you receive your approval letter from Medicare on June 25th, then you will be able to bill for dates of service April 1st forward.

If you are enrolling with Medicare as a DMEPOS supplier, expect a longer turnaround time period.  In addition to close scrutiny of your enrollment application, you must undergo a site visit as part of the application process.  The site visit inspector will ensure your office is located at the address on the application, the hours of operation, where inventory is stored, and other elements required to participate as a DME supplier.  Expect a total turnaround time of 90 – 120 days.

Can nCred make the credentialing process quicker

No.  We cannot make insurance companies process your credentialing application any faster than they normally would.  Our efficiency is managing the overall process, preparing the initial credentialing applications, and regular follow-up on submitted credentialing applications with carriers.  We do, however, understand the process well and avoid mistakes often made by providers attempting to handle the process themselves and thereby improve credentialing times.

Do I need a service location to begin credentialing

Yes.  Before beginning the credentialing and contracting process for a new medical clinic, you must have a place of service.  You cannot use a home address as your clinic address in the interim.  You may use a home address as your billing and/or correspondence address, but you must provide a physical address where you will see patients.  If you are in the process of build-out of a new office space, you can utilize the address of the office space being completed.  Medicare allows you to submit enrollment applications 30 days prior to the start of seeing new patients at a location.  Most commercial carriers follow the same guideline.

How do I complete Medicare Revalidation

Revalidation of your Medicare enrollment record is required every 3 years.  For an individual provider, complete the CMS855I paper application or use PECOS to complete the revalidation online.  For a group/supplier record, complete the CMS855B application. If you have not previously setup Electronic Funds Transfer for your group record, you will be required to do so when you revalidate your file.

You have 60 days from the date the revalidation letter was issued to respond to your Medicare carrier.  Do not delay or disregard this notice, or your billing privileges will be terminated.

Which Medicare application is used for provider enrollment

The CMS 855I is used for individual provider enrollment in the Medicare plan.  The 855I can be used by physician and non-physician providers.  Supporting documents and details required by the application vary by provider types.

In addition to the 855I, in certain situations, new providers will need to submit the CMS460 to elect participation in Medicare.  Without the CMS460, a new provider will be enrolled as a Non-Participating provider.  Non-PAR providers receive less reimbursement from Medicare, but can pursue more reimbursement from the patient (up to 115% of the Medicare rate).

If you are enrolling under an existing group practice, then you will need to also file a CMS855R.  This form “re-assigns” your financial payments to the business entity under which your services are performed.

Whether you are enrolling as an individual or a new group practice, you will need to submit a CMS588 to setup Electronic Funds Transfer to receive Medicare payments.  Medicare does not issue paper checks and will only pay for claims using EFT.

Summary of applications:

  1. Solo practitioner forming a new business entity: CMS855I, CMS460, CMS588
  2. New provider joining an existing group: if already in enrolled with the state intermediary – form CMS855R; if not enrolled with the state intermediary – forms CMS855I, CMS855R
  3. Form CMS460 may be required for new enrollment depending upon the status of the group/supplier
What is a CP575

CP575 is the confirmation letter that you get from the IRS when you obtain a Employer Identification Number – EIN or “Tax Id#” for a business.  To enroll with Medicare, you must provide a copy of this letter as proof of the legal name of the business.  If you do not have the original CP575, then you can request a replacement letter 147C to verify your EIN.  These two documents are the only documents that Medicare accepts as proof of your EIN.

Click here for an example of a CP575 To request a replacement letter 147C, you can call the IRS business center at (800) 829-4933. The hours of operation are 7:00 a.m. – 7:00 p.m. local time, Monday through Friday.