How to Navigate the Credentialing Process for a New Practice
Setting up a new practice can be a huge undertaking, especially when it comes to the credentialing process. Credentialing is the process of verifying and validating your qualifications, experience, and reputation in order for you to be eligible for provider networks. It’s important to understand the length of this process and how best to navigate it when setting up a new practice. Let’s take a closer look at the credentialing process and what you need to know.
Requirements to Apply
Most of this information will be located in your CAQH profile, so ensure that your CAQH profile is up to date with all practice locations information and copies of licenses and PLI are updated and approved when you attest.
An active National Provider Identifier (NPI).
Sole Proprietors only need a type 1 (individual) NPI
Solely Owned Organizations need both a type 1 (Individual) NPI and type 2 (Organization) NPI
National Plan and Provider Enumeration System (NPPES) User ID and password. Internet-based PECOS can be accessed with the same User ID and password that a physician or non-physician practitioner uses for NPPES.
For help in establishing an NPPES User ID and password or assistance in changing an NPPES password, contact the NPI Enumerator at 1-800-465-3203 or send an e-mail to customerservice@npienumerator.com.
Personal identifying information. This includes:
Legal name on file with the Social Security Administration
Date of birth
Social Security Number
Schooling information. This includes:
Name of School
Graduation year
Professional license information. This includes:
Medical license number
Original effective date
Renewal date
State where issued
Certification information. This includes:
Certification number
Original effective date
Renewal Date
State where issued
Specialty/secondary specialty information
Drug Enforcement Agency (DEA) number (if applicable)
If applicable, information regarding any final adverse actions. A final adverse action includes:
a Medicare-imposed revocation of any Medicare billing privileges;
suspension or revocation of a license to provide health care by any State licensing authority;
revocation or suspension by an accreditation organization;
a conviction of a Federal or State felony offense (as defined in 42 CFR 424.535(a)(3)(A)(i)) within the last ten years preceding enrollment or revalidation;
or an exclusion or debarment from participation in a Federal or State health care program.
Practice location information. This information includes:
Practitioner's medical practice location
Legal business name of a solely-owned Professional Association, Professional Corporation, or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575
Special Payment Information
Medical Record Storage Information
Billing Agency Information (if applicable)
Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required to operate as a health care facility.
Electronic Funds Transfer documentation - mechanism by which providers and suppliers receive Medicare Part A and Part B payments directly into a designated bank account (voided check)
The Length of the Credentialing Process
The length of time it takes you to complete your credentialing will depend on several factors, such as which provider networks you are applying for and how quickly they process applications. Generally speaking, however, most credentialing processes take between 6-12 months from start to finish. It’s important to factor in this amount of time when setting up your new practice so that you can plan accordingly.
As a healthcare professional, I understand how necessary it is for the credentialing process to be thorough—it ensures only qualified individuals are able to practice. That said, it is no secret that the process can be drawn out and complex. It is not unusual for some individuals to experience months of delays along their journey towards obtaining the credentials needed for their roles. Even with our experts reviewing each step of the vetting process, it may still take time before everyone’s documents are finalized and verified. This can range from weeks to months depending on various circumstances.
Common Challenges When Applying for Group & Individual Contracts
One of the biggest challenges when applying is getting accepted into new provider networks or being denied due to the panels being closed.
Depending on where you live, certain providers may not accept new physicians in their network or may have long waiting lists for acceptance due to demand in certain areas.
This means that even if you are accepted by one payor network, there may still be difficulty getting credentialed due to lack of acceptance into other provider networks in the area.
You should also research potential appeals processes if you are not initially accepted by a particular provider network; many hospitals and health systems offer appeals processes if an initial denial has been issued due to lack of available space in their network(s).
Overview of Potential Appeals for Network Rejection
If you have been rejected by a particular provider network due to lack of availability or capacity issues, there may be an appeals process available through that hospital system or health plan in order to try again at a later date; however, these types of appeals can be difficult and time consuming so it’s important to research each situation carefully before submitting an appeal request.
When you apply to become a healthcare provider with a network, it is important to follow the criteria closely and re-apply every six months if necessary. It is not uncommon for networks to be impacted by geographic limitations, meaning they may not accept new providers in the area. However, given changes in population growth and other circumstances, these networks may periodically open up additional slots for new providers - keeping an updated profile can help ensure you are among those notified when this occurs. Being persistent and patient is highly recommended whenever undertaking an application process such as this; chances are your efforts will eventually be rewarded.
Transferring Group Contracts (rare)
When transferring group contracts, there are several things that must be taken into consideration.
Your contract status should always be considered before attempting any changes since some contracts may have non-compete clauses or other restrictions that could prevent you from making changes without penalties or other consequences.
Not all contracts allow for easy transferability; understanding your contract status is key before making any moves with existing groups or networks.
Strategies for Re-Applying Every Six Months If Networks Don’t Accept New Providers in the Area
If there are no appeals processes available at this time or if an appeal was unsuccessful after submission, then another option would be re-applying every six months until acceptance is granted by one or more providers; this strategy allows for continued attempts at gaining access without having long wait times between applications submissions which can lead to delays with setting up your practice as well as delays with receiving payments from those providers once accepted into their networks.
In Conclusion
The credentialing process can often seem daunting but understanding its importance—as well as how best to navigate it—will help make sure that your transition into starting up your own practice goes smoothly and without too much delay along the way! Knowing what type of documentation is needed upfront will help save valuable time during this process while also helping ensure that all necessary credentials are obtained prior to applying with any potential provider networks within your area. With proper preparation and knowledge about how best manage this process, starting up a new practice should go off without too much trouble!
Taking proactive steps to ensure your contract status is up-to-date and in compliance with each plan is essential for a successful healthcare practice. Communications with each plan to verify details of the contract and receive instructions on how to set up the new practice will position you for success. Taking time to make sure all details are verified, understood and followed will help ensure timely reimbursement of claims, streamline administrative processes and allow you allocation of resources in other areas that are beneficial to your practice. Put in the effort now to ensure proper contract status and setup - it will be worthwhile in the long run!