Provider Credentialing FAQs

Provider Credentialing FAQs can be found below this page for further information and frequently asked questions regarding our Provider Credentialing & Enrollment services.

Provider Credentialing FAQ’s

What is payer enrollment, credentialing, and contracting?

Payer enrollment is an integral part of revenue cycle management and it includes the steps for a provider to join a specific insurance network. Payer enrollment includes two key processes of credentialing and contracting, which could vary based on the payer.

Credentialing is when a provider submits a participation request to the payer they would like to be in-network with. Once the application is submitted, the player performs a thorough credentials verification process to ensure that the provider meets the credentialing requirements. When the credentials verification i.e. primary source verification is complete, the credentialing file goes to the credentialing committee for approval. Once approved, the contracting process begins.

Contracting is when a provider has been approved by the credentialing committee and is extended a contract for participation in the network. The provider then reviews the contract received, including legal language, terms, reimbursement rates, and other responsibilities of participation. If the provider is satisfied with the contract, then they sign the agreement, and an effective date is received with a provider number. The provider can then begin billing that payer and receive in-network reimbursements for their claims.

How long does it take to get enrolled?

The entire process can take anywhere from 120 to 150 days to fully complete enrollment. Once TriumpHealth gathers the necessary information and completes the applications for all payers, the applications are submitted to the payer. Each payer committee reviews applications once per month and this date differs based on payer.

What can I do to speed up the process?

There are a number of steps that can be taken by a provider to ensure that the credentialing process goes as smoothly and as quickly as possible. One of the most important things is to have all the documentation needed to file the application gathered and readily available ahead of time. Secondly, most commercial payer enrollment will take 120-150 days to complete, so do not wait until the last minute. Be sure to plan ahead if you know your desired billing date so that you can meet your goals.

Additionally, it is helpful to have your CAQH account current, so that payers can utilize the correct information without having to ask for document updates, which will delay the process. Also, it is very beneficial to know the key payers that you would like to be enrolled with. TriumpHealth can help you find the payers that would be beneficial to you as a provider, but the enrollment process can begin much faster if you already have a list of payers in mind.

What is CAQH?

CAQH (Council for Affordable Quality Healthcare) ProView is an online database for storing provider information such as specialty, DEA, license, education, malpractice, CV, and legal records. It eliminates duplicate paperwork with healthcare organizations that require your professional and practice information for claims administration, credentialing, directory services, and more. Most payers require updated CAQH databases for each of their applicants to effectively access and verify their personal information during the enrollment and contracting process. Due to this requirement, a complete and current CAQH is necessary to begin the credentialing process.

How do I participate with CAQH?

In order to create an online profile, you need a CAQH ID, username, and password for the CAQH website. With the Proview system implemented by CAQH, it is required that you contact CAQH directly to acquire a user account. TriumpHealth can handle each step of this process for you and make sure that your account is created, updated, and stays current.

What documents are required by insurance companies (payers)?

The documents required may vary based on the type of provider and insurance company. Here is a list of basic documents that may be needed:

  • Practitioner License(s)
  • Malpractice Insurance (Certificate of Insurance)
  • DEA and State CDS Certificates
  • Board Certifications
  • Diploma (a copy of the highest level of education)
  • Current CV (showing current employer)
  • IRS form W-9
  • Current Driver’s License

TriumpHealth will ask you for the required documentation for each application, in order to make your experience is as smooth and hassle-free as possible.

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