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Re-Credentialing or revalidation is the dreaded date circled red on your calendar that might bring you a sleepless night or two. There are so many important components to re-credentialing which involve different due dates for commercial plans versus government plans, and then understanding how to navigate CAQH, one can understand the anxiety. Hopefully the provider records have been kept up to date, otherwise in order to update that information you will need to gather up those documents. Some of the information you might need would be malpractice claim details, licenses, CME details, training certificates, just to name a few. Knowing when to begin, how to keep your data organized and up to date and then how to submit all of the information needed is part of the struggle of the re-credentialing process.

Re-credentialing for most commercial plans is required every two – three years. Keeping up with payer re-credentialing requirements for managed care plans is extremely important, especially if they include rate changes. Renewals need to be completed on time. If you are up to date in the CAQH ProView, you likely will not have to do anything else for that commercial plan. Most commercial plans have credentialing and re-credentialing guidelines on their website but sorting through them can be very time consuming.

In order to keep your CMS billing privileges active, re-credentialing (“Revalidation” or “Re-Enrollment”) is required every five years. Off-cycle revalidation requests are not uncommon in special situations. Your organization will receive a notice approximately three months before your revalidations are due. This notice may come by mail or email. In addition, CMS began publishing revalidation due dates several years ago. The upcoming revalidations are published six months in advance on the CMS Data Website. Prior knowledge is important when dealing with Government plans as there are no extension, and if you do not revalidate your enrollment record your billing privileges will be suspended and there is no retro activation when you finally do re-enroll. Therefore, you will lose reimbursement for any services provided during your period of inactivation. Supporting documents may be requested if changes have been made to the provider’s file.

medicare provider enrollment re-credentialing and revalidation

A special note about CMS revalidations is that all revalidations were halted during the pandemic. CMS will restart revalidations processing sometime soon.

Finally, is the CAQH or Council for Affordable Quality Healthcare. Since this is the re-credentialing process, your provider should already have a CAQH id number and their information should already be loaded in CAQH ProView. The normal process is to be attesting your CAQH profile every 90 days, up to date information should be stored in there for re-credentialing already. Remember to update CAQH anytime there is an update to your provider’s record, even if it is just an address change. It is also important to keep current document copies in your CAQH file including medical licenses, malpractice insurance, board certifications, training certificates, and other supporting documents for your specialty. Doing so will eliminate any issues during the re-credentialing process.

Failure to comply with re-credentialing guidelines can have a serious impact on your practice. Gaps in coverage and claim denials will occur if you miss deadlines. Worst case scenario is to lose a patient over these mistakes. If you are uneasy about provider re-credentialing or this process, please contact us for assistance. We are credentialing professionals with extensive experience in Medicare, Medicaid, CAQH, and commercial carriers. Consider saving your group time and labor costs sorting through the re-credentialing process, and give us a call at (423) 443-4525 or email us at info@nationalcredentialng.com. Our credentialing professionals are located in the United States and our team has extensive experience working with health plans to complete the provider enrollment/credentialing process.