Accurate and timely provider enrollment has a dramatic impact on cash flow of any practice.  The ultimate goal of any business office, credentialing office, or other responsible staff is to have providers enrolled with health plans as quickly as possible and to maintain that participating status.

To get the process started it is essential that providers furnish complete credentials information to the appropriate staff as quickly as possible.  The information needed includes background information on education, training, experience, and personal identifying information.  A complete credentialing file will allow your appropriate staff member, or outsourced partner, the ability to complete the enrollment process without having to continually go back to the provider for additional information.

Some important required documents needed for your credentialing file include:

  • Practitioner License(s)
  • Malpractice Insurance (Certificate of Insurance)
  • DEA (federal) and state CDS certificates
  • Board Certification(s)
  • Diploma – copy of highest level of education (M.D., D.O, etc)
  • Certificates of completion for all medical training (intership, residency, fellowship)
  • Current copy of CV (showing current employer)
  • ECFMG Certificate (if educated in foreign country)
  • Passport or other citizenship documents (if born outside the U.S.)
  • IRS Form W-9
  • Current driver’s license
  • IRS form CP575 or replacement letter 147C (verification of your tax id#)
  • CLIA Certificate (if applicable)
  • Business License (if applicable)

A complete credentialing file with all supporting documents allows your staff or outsourced credentialing office to:

  • Maintain accurate and current provider information records and provider documents
  • Complete facility privilege applications and insuranc network credentialing/enrollment applications on the providers’ behalf
  • Maintain your CAQH profile to allow carrier and hospital credentialing offices to have access to the necessary information and documents to perform their verification/credentialing processes
  • Improves the turnaround time of your credentialing/enrollment applications which in turn improves cash flow for the practice

A complete CAQH profile is an important part of the credentialing process.  CAQH is an online data repository of credentialing information that can be accessed by participating insurance networks and hospitals.  A providers’ credentialing staff should maintain the CAQH profile with accurate and up to date information and keep copies of supporting documents current in the providers file.  A complete CAQH profile is another step in the process that can make for a timely turnaround of your applications and thereby affecting cash flow for your practice.

While CAQH maintains much of the providers credentialing information, that in and of itself does not represent the entire credentialing process.  In addition to having a complete CAQH profile, each insurance network or hospital will require some paperwork submission.  In addition, you’ll need to continually follow up on your submitted application to ensure it is moving along in the process.

Provider NPI records are another area that need attention when credentialing a new provider.  It is important to have the providers username and password for the NPPES website so that the NPI file can be maintained.  Provider’s NPI files should be accurate with correct practice addresses, provider numbers, taxonomy codes, and contact information.  These files should be reviewed for accuracy prior to submitting any credentialing application.

The providers NPI username and password are also important for enrollment in the Medicare program.  The online enrollment system, PECOS, uses the providers’ NPI login as the login for the Medicare enrollment system.

Providers starting a new practice may want to consider outsourcing the credentialing process.  There are enough business issues to deal with in getting your new practice off the ground, and with credentialing playing such an important role in cash flow it is a good idea to consider hiring an organization who does this type of work on a daily basis.

Considering the important role of credentialing to the financial health of any medical practice, it is imperative that every provider, administrative staff, our outsourcing partner process and follow up on applications in a timely manner.  Ultimately the turnaround time of any insurance network application will depend upon the effective processing by the insurance company, but timely submission and follow up will help ensure the best possible turnaround time of your enrollment applications.

Key points to remember about the credentialing process include:

  • Start early – don’t wait a month prior to opening to begin the process
  • Have a complete credentialing file together before beginning your applications
  • Continuous follow up on your application after submission

It’s important to get this process right and to get it right the first time!

Call nCred today at 423.443.3840 opt#1 or email to request more information about our credentialing services.