All

Credentialing Process & Key Milestones

achievement
14 Oct

Credentialing Process & Key Milestones

Becoming a credentialed provider is a lengthy and complicated process and the timeline to get credentialed can differ from payer to payer. When sending applications to become an in-network provider with a payer, it’s important to remember internal processes. These processes must take place to credential you properly and make you available and visible to covered patients.

Keep in mind that governmental insurance plans like Medicare, Medicaid, and CHIP have more tedious processes than commercial insurances like Blue Cross Blue Shield, Cigna, and United Healthcare. This is due to the extra liability that governmental plans have regarding their patients. Each provider and practice is thoroughly verified to ensure compliance before being allowed into the payer network.

Below are the steps and average timeline taken by insurance companies to completely credential a provider into their network.

Send a Provider Interest Form

  • Expect a response within 10-15 days on whether the payer is accepting new providers in that region.

Send Application

  • Normally the credentialing panel meets once per month, and this frequency could be once per quarter, depending on the payer. The day the panel meets also differs from payer to payer
  • Missing or late documents may delay the application to the next meeting date.
  • If everything is filed and submitted correctly, normally the payer will acknowledge receipt of application-in-process within 30-45 days

Application Accepted

  • If accepted, the payer may provide a preliminary agreement or proposed contract with reimbursement rates for review and approval.

The internal payer filing process begins

  • Once the provider signs and the contract is fully executed, the payer files and sends provider information to all advantage plans associated with that payer
  • The payer alerts customer service so that when the patients call, the provider is recognized as an in-network provider for covered services

The entire credentialing process may take anywhere from 120-150 days for a provider to be in-network

Keep in mind that even after the provider is in-network with an activation date, the payer system may take one week to 90 days to load the provider contract.

If you are facing any of the following credentialing challenges:

  • Too much credentialing paperwork or simply don’t have enough time in the day
  • Inaccuracies in payer applications or issues with auditing of credentialing paperwork
  • Struggling to keep track of payer applications
  • Setting up a new practice
  • Adding new providers to your practice or organization
  • Opening up a new location or changing locations
  • Losing revenue due to credentialing denials

Please feel free to contact us today, so that an experienced TriumpHealth credentialing specialist can provide you with an expert advice and dedicated support. We are here to help you navigate the credentialing process and maximize revenue.