Health plan credentialing (Enrollment) for Nurse Practitioners can bring about some unique challenges.  Providers who are operating an outpatient clinic as a primary care provider will need to be directly credentialed and contracted with health plans.  Know the hurdles that you face before beginning the process.

Not all health plans credential Nurse Practitioners

Some plans do not separately credential nurse practitioners, but allow NP’s to bill as the supervising physician.  A provider who desires to operate as a primary care provider and accept insurance, should first determine which health plans are important for participation in their respective market.  Then you have to find out which of the plans credential NP’s.  The variation of credentialing by health plans vary by market.  Some plans that credential NP’s have full panels and may not be accepting new providers.  You won’t know the answer to either of these issues until you contact the plan.  A phone call can determine if a plan credentials NP’s and most often can accomplish finding out if the panel is open in your area.

Challenges with enrollment

License restrictions

License restrictions vary from state to state for Nurse Practitioners.  Some states are “Full Practice” states which allows NP’s to evaluate patients, diagnose, order and interpret diagnostic tests, prescribe medications, initiate and manage treatments under the exclusive licensure authority of the state board of nursing.  In these states, an NP can enroll with health plans with little variation in the process from that of a Medical Doctor.

Reduced practice states require a regulated collaborative agreement with a physician in order to provide patient care.  The collaborative agreement is a necessary part of credentialing with health plans in these states.  Without a complete and executed document that meets state requirements, you will not be able to proceed with the credentialing process.  A helpful hint for all Nurse Practitioners is to always maintain a legible and current collaborative agreement accessible at any given time.

The final type of license restriction is “Restricted”.  Restricted practice states require supervision, delegation, or team-management by an outside health discipline in order for the NP to provide patient care.

Click here for complete information about license restrictions by state.

Hospital admitting privileges

Many health plans require its providers to have admitting privileges at an in-network facility.  If a provider does not have admitting privileges, then you will need to prove an “Admitting Relationship” with another provider.  This should be in the form of a letter, on the letterhead of a physician, who states that he/she will handle all inpatient admissions for your patients when necessary.  Regardless of where you practice, if you do not have hospital admitting privileges then go ahead and get such a relationship in place and have an admitting arrangement letter ready for your credentialing process.

This requirement is often frustrating to providers who are operating in a setting that will not have situations requiring in patient admissions.  Regardless of your type of practice, have this documentation ready for your credentialing process before you begin if you do not have admitting privileges at an area hospital.  You will not be able side step this requirement, so know that going in.  It is also important to note that your admitting privileges or admitting relationship provider must be at an in-network hospital.  So an admitting relationship with a provider who does not participate with UHC, for example, will do you no good when you apply to UHC; or your privileges at XYZ hospital will do  you no good if XYZ does not participate with UHC.

Your Credentialing File

Throughout your career, you should maintain a complete file of all your credentialing data and document copies.  Whether for facility privileging purposes or insurance credentialing, there will routinely be times that data or documents are needed for initial or re-credentialing reasons.  Here are a list of documents to maintain in your credentialing file:

  1. Current CV (including mm/yyyy for all education and work history entries)
  2. State license(s)
  3. DEA/CSR
  4. Prescribing arrangement letter if you don’t have DEA certificate
  5. Professional liability insurance
  6. Copy of diploma from highest level of education
  7. Board certificate
  8. Collaborative Agreement
  9. Admitting arrangement letter
  10.  Current drivers license

Be prepared

If you are starting a new practice or have a new Nurse Practitioner joining your medical group, don’t wait till the last minute and don’t expect the insurance credentialing process to not require your attention.  Know your license restrictions if any, have all your documents together, and know what health plans you want to target for participation.

Engaging nCred to help with your credentialing needs can assist you by providing you with qualified staff to guide you through the process and work on your behalf with each insurance company.  Our staff will put in the time necessary to follow up with each plan throughout the process to ensure your application is progressing.  Our online software platform also gives you the perfect method for maintaining all your credentialing information and documents in one easy to access place.