What is meant by the term “Healthcare Credentialing”?

Meaning of the term “Healthcare credentialing”; who utilizes it and For What Purpose

​“Healthcare credentialing” is usually referred to the procedure of evaluating training, education, and proven qualities of the healthcare practitioners.  During the time period of credentialing procedure, the required steps involve checking out the license(s), recognizing the medical schools and monitoring the completion of medical education, verify practices and training like residency, internships and other items.  Implementation of the verification process is done by going to the “Primary Source”, which means going towards the entity or organization that had offer the education, license, or other credential to determine the authenticity of the data provided by the healthcare contributor.  The evaluation process of licences and education can be very time consuming relying upon the particular items that needs to be checked and verified.

The healthcare facilities use the credentialing process for giving permissions to practitioners to provide required services on its campus, health policies to permit contributors to get involve in its network, medical group when employing new providers, and other healthcare organizations that have a requirement to hire or otherwise involve providers.

The Process of Provider Enrollment
The process of provider enrollment basically means making a request of participation in a health insurance network as a “Participating Provider”.  The process includes making a request of enrollment/contracting with a plan; submitting required copies of licenses, finishing out the plans credentialing/enrollment application; insurance, and other important documents; signing an agreement; and any other measures that might be distinctive to a carrier.

After receiving the request of provider enrollment, health plans utilize the process of credentialing to make sure that the provider is quite educated, trained, and meets any other particular requirements for participation in network enrollment.  After completing the process of credentialing, the provider will be given an agreement for participation by the network.

The processing time of provider enrollment usually differs by payor.  Certain commercial plans consumes up to 180 days in completing the process of credentialing and then furthermore 30 – 45 days for contracting, while other have the entire credentialing and contracting complete within ninety days.  During the submission of the required documents for the process of enrollment, contracts, or following up on applications, it is very significant to document your whole steps by utilizing certified mail, fax logs, email, overnight mail services etc and documenting phone negotiations with agent names and contact details.

While now there has been several service companies that are helping the healthcare providers with the process of enrollment for a fee. Entire paperwork and follow up with the insurance companies on behalf of the provider will be look after and managed by these service companies. The worth of these services depends on the time saved and general expertise of addressing with insurance companies on routine basis.