Provider Credentialing & Enrollment

Medical credentialing is the process of verifying a healthcare provider’s education, training, experience, and qualifications to ensure they meet the standards and requirements to provide medical services, and is important because it helps ensure the quality of care provided to patients and protects the reputation and financial stability of the healthcare organization.

The steps involved in the medical credentialing process include gathering and verifying relevant education, training, and professional experience documentation, submitting an application to insurance companies, participating in site visits and audits, obtaining necessary licenses and certifications, and ongoing monitoring and reapplication to maintain credentials.

The time it takes to complete the medical credentialing process varies and can range from several weeks to several months, depending on the insurance companies and their requirements, the completeness and accuracy of the submitted information, and the responsiveness of the healthcare provider and their staff.
At Advanced RCMS, we’ll help you to get credentialed/contracted with your most desired Insurance companies within 45 to 90 days, depending on the Insurance companies and their requirements.

We do not stop even there is a rejection of an appeal or new application. Our job is to get our client enrolled with Insurance. We have the experience needed to handle rejected cases in enrollment and second level appeals, to help our clients to become accepted by the Insurance.

Yes, you will have assigned credentialing specialist that will be the primary person for communication between you and insurance company. You will be able to speak with the Credentialing Department Supervisor and Manager.

No, submitting an application to the insurance does not provide a guarantee that insurance will accept provider into the network. Before submitting the application, it is crucial to find out if the panel is open for the provider specialty. Once the confirmation has been received, the application can be submitted.

The criteria for a healthcare provider to be credentialed typically include verification of education, training, and professional experience, demonstration of professional competence, passing a background check, obtaining necessary licenses and certifications, meeting any relevant state and federal regulations, and adhering to the standards and guidelines set by insurance companies and accrediting organizations.

Medical credentialing affects a healthcare provider’s ability to bill for services by determining which insurance companies the provider can participate with and the types of services they can bill for, as well as influencing the reimbursement rate for services rendered. Healthcare providers who are not credentialed may face difficulties in securing payment for services and may be limited in the types of patients they can treat.

Primary source verification is an essential step in medical credentialing that involves confirming the accuracy of a practitioner’s qualifications, licensure, and professional background directly with the original sources, such as medical schools, certification boards, and state licensing agencies.

The frequency of credentialing renewal for healthcare providers varies, but it is usually required every two to three years to maintain their privileges and ensure the continued quality of care.

The consequences of not maintaining up-to-date medical credentialing can be significant, including loss of privileges, reduced insurance reimbursement, legal issues, and damage to professional reputation, which can ultimately impact the ability to provide patient care.

A healthcare provider can ensure they have all necessary information for medical credentialing by thoroughly gathering and organizing their qualifications, licenses, certifications, insurance, and professional references in a complete and accurate manner.

The National Provider Identifier (NPI) is a unique identifier assigned to healthcare providers by the Centers for Medicare and Medicaid Services (CMS) that plays a critical role in medical credentialing as it is often required by healthcare organizations to verify a provider’s identity and qualifications during the credentialing process.