Insurance Credentialing - Tips and Resources

Insurance companies have special departments dedicated to provider enrollment and keeping track of participating provider’s information. This department is often called the credentialing department. To begin provider credentialing, you must call each insurance company’s credentialing department and ask the insurance what type of application you will need to complete to credential a new provider.

 There are three different types of applications of which the insurance will require one. The first type is an insurance specific application. That means that the insurance requires you to use an application created by them. This application will either be a paper document that they will give to you via mail, email, or download or the application may be available electronically on the insurance company’s website.  The second type of  application is a generic credentialing application created by a state government agency like your State Department of Banking and Insurance, called the Universal Application. To see some examples of Universal Applications and get a feel for what information is required to credential a provider, take a look at these links and study the Universal Credentialing forms:

New Jersey: http://www.state.nj.us/dobi/division_insurance/managedcare/mc_5application.pdf

Oregon: http://www.oregon.gov/OHA/OHPR/ACPCI/docs/2009/CredAppGloss.doc

The third type of application is an on-line credentialing software called CAQH (https://upd.caqh.org/oas/). CAQH, in my opinion, is the best option if it is available.  It is free, widely accepted and saves  time and paper work. The provider or credentialing specialist logs in to a secure web site and completes a Universal Application online. Then, you fax any supporting documents to CAQH for upload to the provider’s account. Once the universal application is done and the supporting documents are received, you can call the insurance companies that participate and give them the provider’s CAQH ID number so they can retrieve the application and documents electronically.

Insurance participation is a contract between the provider and the insurance. A such, most insurance companies will require a signed contract in addition to the application and supporting documents. The contract must be obtained from the insurance company. Most paper credentialing packets have contracts included with the applications but if you opt to use a service like CAQH, you must request contracts from the insurance separately. These contracts will need an original signature by the provider who is being credentialed. Sometimes, the insurance company will ask you not to date the contract this is because the application can take a long time to process and they want the contract to be dated close to the approval date. Check with the insurance about this so that there is no delay in the application.

Once you have determined what application will be required by the insurance you will need several documents for the applications completion. Many of the same documents will also be photo copied and submitted as proof with the application. To follow is the list that you may need:

1.                  CV. A is a curriculum vitae which is a very detailed résumé. It must include all of the provider’s education information, from undergraduate degree through medical school, residency, fellowship, the entire work history with an explanation for any gaps in work of more than 6 months, any special education beyond typical medical school (example special training for children with ADD), and a list of professional writings or articles. All of the above must have a beginning and ending date including month and year.

2.                  Malpractice history. The credentialing specialist must obtain a complete history from the physician or their attorney on any previous or pending legal action against the doctor for medical malpractice. If there has been any history of suit you must know the date the accusations were filed, the date the suit ended or settled the details about the allegations against the doctor, the outcome (judge’s decision or settlement). Cases settled or completed may require a letter from the provider’s attorney stating the settlement/completion details. This must be a complete list not excluding any details since all of the facts are listed and checked as public record in the National Practitioner Databank (http://www.npdb-hipdb.hrsa.gov/). If the insurance feels that the provider is leaving out details or misrepresenting themselves their application can be rejected permanently.

3.                  Medical License. Medical licenses contain a license number, effective and expiration date. All of these will be needed for the application, plus you must submit a copy of the license with the application.  

4.                  DEA. The DEA certificate (Drug Enforcement Agency) has a DEA number which usually begins with two letters, an effective date and an expiration date. This information will be necessary to complete the application and a copy is needed to send with the application.  If the provider misplaces the DEA form, a duplicate can be retrieved from the DEA’s website at https://www.deadiversion.usdoj.gov/webforms/dupeCertLogin.jsp

5.                  Malpractice face sheet. This is a letter or certificate from the malpractice insurance company showing the provider is covered by a policy in case of malpractice action. This letter will contain the name address and phone of the insurance company, the policy number, and the coverage amounts (usually $1 million/$3 million). You must complete the application with this information and send a copy of the form with the application.

6.                  Professional references. Other doctors who will agree that your doctor is competent to practice medicine. Usually it is only necessary to provide that reference’s name, phone number and address.

7.                  Hospital privilege attestation. This is a letter that can be obtained from the hospital where your doctor has privileges by contacting the Medical Staff Office. The letter will usually be faxed to you stating the level of privilege (full, attending, consulting etc.) and a effective and expiration date.

8.                  Provider’s personal information. Including full, legal name (nick names don’t work), NPI, date of birth, place of birth, proof of US citizenship or appropriate documents for long term residency and working in the United States, social security number, marital status, sex, etc.

9.                  Provider’s signature on each application and all contracts. You will need to have the provider’s original signature on all forms.

All of this information will help you to fill out a lengthy application which should then be sent to the insurance credentialing department for verification and processing. The application processes vary by insurance and consist of a period of review by a specialist who checks that all information is present and valid. Once this initial review is complete, the application is usually reviewed by a credentialing board for final approval. After the board approves  a provider’s application, a welcome letter is generated  and the process is complete. Simple, right? NO!

Insurance company’s credentialing departments get hundreds of applications, both initial and renewals. Credentialing takes a LONG time and a lot of follow up. With such high volume, mistakes happen. I have experienced lost applications, newly credentialed providers with the name but wrong tax ID number or NPI, and worse. It is imperative that the application process be followed closely.  In order to be sure that the application goes through smoothly, here are some recommendations:

1.                  Create a folder for each insurance company. Here, you will keep all documentation and information that you may need for reference.  Find a good place to store these folders. The folders must be easily  accessible in case you need to refer to them – if for example, the insurance calls you for clarification.

2.                  Staple or tape a few pieces of paper to the inside front of the folder. These will be used to log your follow up calls to the insurance. After you have submitted the application, you must call the insurance regularly to inquire about the status of the application and to ask if they need anything else from you. When you call the insurance for follow up on the status of the application, ALWAYS get the name of the person who you are speaking to – force accountability.  After every call, record the details of follow up call in to your follow up log. Be sure to include the name of the person to whom you spoke and the date when you talked to them.  

3.                  Filling out the credentialing applications can be tricky. If the insurance company asks a question on the application and you are not sure what a question means or how to answer it, call the insurance company and ask them. Don’t run the risk of sending incorrect information as that will just delay in the application’s processing time.

4.                  Quadruple check the application before submitting it!!!! Make sure that you have not excluded any information or made any typographical errors.

5.                  For paper applications, make a copy of the entire completed/signed credentialing application, all attachments, and the signed contracts. Keep a copy (send the original to the insurance) in the correct insurance’s folder mentioned in tip 1. Record the date that you mailed the application on log sheet recommended in tip 2. To ensure accountability consider sending paper (mail in) applications certified.

6.                  Call the insurance’s credentialing department to check on the status of the application. Allow appropriate mailing time, if appropriate, then call to see that the application was received. You should ask if any tracking number has been assigned to the application, if there is one, write it down on the log sheet in tip 2. Ask the name and phone number of the insurance representative who is processing the application. Record all of this information on your log sheet from tip 2. 

Ask the representative how long processing takes and when you can reasonably call again to follow up. You don’t want to be too bothersome, because the representatives are very busy and you will do better respecting their time than making them mad.  Still, you must follow up at regular intervals. When you call be polite no matter how long it takes, no matter how long you are on hold! If you want their help in processing quickly or guiding you through any necessary revisions, you will get much more help from them if you are respectful and polite. Remember the old adage, you get more flies with honey than vinegar. 

Call back to check up on the application regularly, for example once per weeks or every two weeks is acceptable. In these calls verify that the application is processing without any problem and ask the insurance if they need any additional information from you. If they do need any information, send it promptly according to the method that they specify (fax, mail, email, upload)!!! Record the method by which you sent the document, to whose attention it was sent, and the date sent in your log sheet referenced in tip 2. After new information is sent,  call the insurance to confirm receipt.

This can be a very smooth process, but that requires extreme accuracy. Remember that the insurance’s credentialing specialist will verify all of the information so any errors, will delay the application’s processing.  The timing for each insurance’s credentialing varies but you can expect that some will take several months to complete. Accordingly,  before sending the application and any supporting documents make sure that the provider’s licenses and/or certificates are not nearing expiration as this too can delay processing.

At some point the insurance’s credentialing specialist will tell you the application review is complete and either the provider will be going to the review board for final approval or the provider is completely done. Either way ask the representative to confirm the following information to ensure accuracy:

1.                  Tax ID

2.                  Office locations

3.                  Provider name

4.                  Billing address

Upon completion, your doctor will be issued a letter of acceptance welcoming him/her to the insurance network. Finally add the acceptance letter to your folder from tip 2 and file the credentialing folder for that insurance as complete.

Lastly, it is good to know that most insurance companies will require periodic re-credentialing or provider updates. The re-credentialing process is usually much easier and only requires information confirmation and submission of updated licenses, malpractice information and certificates. You will usually receive a re-credentialing packet via mail, fax, or email. Answer the re-credentialing requests promptly and accurately. If the required information in not received in the insurance’s time frame, you can lose your participation status with the insurance company and the only way to get it back is to begin the initial credentialing process over again. That can mean months of waiting.