6 Steps in Provider Credentialing Services

It’s crucial to move a new doctor, nurse practitioner, or other healthcare providers through the provider credentialing procedure as soon as your hospital hires them. In addition to getting them classified as a medically approved provider by the insurance companies you deal with most frequently, this enables you to confirm their credentials and expertise. A healthcare professional must reapply each time they start working for a new employer, even if insurance panels have previously authorized them.

Unfortunately, Provider credentialing is an expensive and time-consuming process that can consume a lot of the resources in your hospital. Bellmedex specialists have developed a guide to assist you in reviewing the six essential processes in provider credentialing services to increase system transparency.

The Value of Certification


To get everyone on the same page on the significance of healthcare provider credentialing, also known as insurance credentialing, let’s address the subject of why credentialing is vital in healthcare before we explore the stages.

To handle insurance claims, the majority of hospitals must confirm the credentials of their healthcare personnel. Credentialing is crucial for ensuring widespread access to care, even if some of your customers lack insurance or pay out of pocket.

For various healthcare organizations, there are several physician credentialing procedures. Credentialing is crucial for doctors, but it’s also crucial for:

  • Hospitals and health agencies
  • Dentists
  • Physical therapists
  • Licensed massage therapists
  • Counselors and psychologists

You must guarantee that your credentialing department complies with the requirements of the following federal authorities in order to accept Medicare and Medicaid.

Beyond these federal laws, every state has its own standards for credentials. Understanding and strictly adhering to these guidelines might help your practice become less liable for potential malpractice lawsuits.

Credentialing is time-consuming and even boring, as we mentioned. Follow these instructions to guarantee that your medical provider gets the right credentials on time.

Determine the Documents Necessary

document is necessary

Be mindful that each insurer has various requirements for documentation and forms as you start the credentialing process in healthcare. Each insurer you intend to work with will require a comprehensive application, and even one missing piece of information can cause a delay of weeks or months in the approval process.

Make a list of all the insurance companies you intend to submit with to verify that your applications are comprehensive. Then it makes a list of all the papers that are needed.

Verify the Information is True

verified information

You should keep in mind that the quality and accuracy of the information are crucial when you start to compile the necessary documents and fill out individual applications.

  • Run a background investigation
  • Verify the person’s reputation, board qualification, and educational background with a healthcare group like The American Medical Association (AMA)
  • The Educational Commission for the Certification of Foreign Medical Graduates (ECFMG)
  • It is called the American Board of Medical Specialties.
  • Examine the history of your credentials, rights, and insurance claims.
  • Describe any punishments that have been reported to the Office of Inspector General (OIG)

Issues may arise if the information is supplied with any mistakes. For instance:

  • The approval procedure may be a delayed if the application needs to be revised with the correct information and if months and dates of employment cannot be quickly and precisely confirmed by previous employers.
  • In the same way, using the wrong phone number for references or former employers might result in delays or even rejections.
  • Absence of prior malpractice claims may result in disqualification.

Revision of the application with the right information can delay the approval procedure if months and dates of employment cannot be quickly and precisely verified by previous employers. The wrong phone number for references or former employers can often cause delays or even rejections. The exclusion of prior malpractice claims is a possibility.

Place insurers first

It could be advantageous to prioritize the dossiers you send first because you’ll need to submit several applications.

  • If a sizable amount of your medical billing businesses process by single insurance, you should first finish the credentialing process with them.
  • Become familiar with the rules that apply to specific insurers. Some insurance providers—like Aetna, for instance—allow providers who are currently covered by insurance in another state to go through a shortened procedure. 2 This might result in faster approvals.
  • For providers who already have in-state credentials, other insurers offer a condensed application.

Wait for confirmation

It’s time to wait for the insurers to approve your application after you’ve put it together and sent it to them. This procedure could take a while. Although the majority of credentialing finish in 90 days or less, experts advise allocating oneself 150 days. 4 Credentialing could take considerably longer if significant problems occur. (Click the provided link to read about healthcare credentialing issues!)

Following Up

Don’t merely wait for insurance to contact you after five or six months. Credentialing healthcare professionals reveal that prompt approval depends on regular follow-ups.

  • Develop connections with important insurance business employees. Applications can advance more quickly if leadership, executive assistants, and other personnel have a good working relationship.
  • To increase your likelihood of receiving a response, check in over the phone rather than by email.
  • If you learn that more information is need, promptly gather and check any relevant documents.

Alex Hales

Bellmedex medical billing company has an experienced and qualified team working diligently, knowing about company policies to get money in minimum time. The RCM Healthcare proficiently managed the sustainability of medical services; along with challenges and complexities, our medical billing company operates efficient billing claims quickly. It's our responsibility to manage and optimize revenue performance.

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