TIPS ON UNDERSTANDING CREDENTIALING

​ TIPS ON UNDERSTANDING CREDENTIALING

THE UNTOLD STORY!

Every state, hospital and insurance provider has different rules, regulations, forms, and requirements for medical credentialing. Finding leading industry experts, like SLJ CREDENTIALING SOLUTIONS, that has the knowledge and expertise to bring that extra edge needed to become credentialed/contracted with hospitals and insurance payers will ultimately achieve larger cash-flow results. The best billing companies and systems in the world will not get your claims paid unless those complex medical credentialing issues are brought to light and resolved.

Managed Care Credentialing

Like hospitals, the Managed Care (Insurance payers), verify several items when credentialing healthcare providers for their networks, including:

• Education/Training (Internships/Residency and Fellowships)

• All State Medical License(s) (Active and In-Active)

• DEA

• CDS (if applicable, State by State Basis)

• Board certification (Even Board Eligible)

• Mal-Practice Insurance coverage

• Work history (Minimum of 5 Years or More)

• Medicare/ Medicaid sanctions

NPDB/Data Bank History (Every 2 Years)

• Malpractice claims history

The Managed Care/Insurance Payer Credentialing Committee approves the provider based on the network need and the provider’s credentials.

Have a Credentialing SWEEP Review done of your Practice.

Ensure that your NPI Provider Numbers (Individual and Group and updated with the correct practice and mailing locations.

Check with your Insurance Payers (Commercial and Government Payers) about your practice, billing and correspondence locations and accurate from time to time. DO NOT ASSUME THEY HAVE EVERYTHING CORRECT IN THEIR SYSTEM!

Be sure that your Billing and Credentialing Departments are communicating with each other when it comes down to enrollment issues.

Allow your Credentialing Staff/Departments attend updates and/or meetings about understanding medical credentialing. It does not hurt to see if their knowledge is up to par!

Know that you need to have your Credentialing Staff to keep a good eye on ALL expire documents and certifications. You never know when you need them in a PINCH!

Ensure that your Credentialing Staff is updating and maintaining all providers CAQH Profiles. More and more Insurance Payers and using this system to update and maintain their systems as well. (Keep your information, practice, billing addresses updated at all times.

Does your Credentialing Staff have good REPORTING procedures in place to help maintain Re-Credentialing for the Insurance Payers and Hospital Privileges? Make sure they understand your practice re-credentialing schedules.