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Credentialing for healthcare professionals is a service that ABCS RCM provides to our clients. We are familiar with the details and requirements of each insurance provider and often have to provide assistance in this area. The insurance credentialing process seems straight-forward. But, as we look at the details, the process can quickly become frustrating.

The insurance provider Humana describes credentialing as “the process of obtaining and reviewing documentation for the purpose of determining participation privilege status in the health plan. Such documentation may be provided by the applicant and/or obtained during the process. The documentation may include, but not be limited to, the applicant’s education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history and professional competence.” This sounds easy enough.

Fortunately, there are ways to minimize the issues surrounding credentialing. Here are three basic steps to follow for credentialing:

  1. Pay close attention to details such as: current work status, NPIs, employment history, existing hospital privileges, etc. Any missing or incorrect information, can slow down the credentialing process.
  1. Maintain your CAQH information: The Coalition for Affordable Quality Healthcare (CAQH) started its uniform credentialing program well over a decade ago. If health professionals regularly update and attest their CAQH information, they will experience fewer credentialing and re-credentialing issues.
  1. Be aware of state regulations: Many states have their own unique rules for credentialing, including reciprocity regulations and in-state credentialing. Contact Advanced Billing and Consulting Services for more details about this in order to ensure that you are using your state’s standards to your advantage.

A health professional should become credentialed with every insurance company that they plan to submit claims to. They will need to follow up on the process and maintain their credentialed “in-network” status with that insurance provider. Again, contact the staff at ABCS RCM if you possess addition questions about this process.

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Credentialing help, CAQH