Requirements for Health Plan Credentialing and Insurance Enrollment

If you intend to see patients with insurance coverage, then you almost certainly will wish to become a credentialed provider with that health plan as well as contract with the insurance company to provide in-network services to its members. The health plan credentialing and insurance contracting processes can be rather tedious, and they tend to stretch over several weeks or months, delaying reimbursements for services, as well as adding administrative burden to you or your support staff. Understanding the requirements for credentialing helps streamline the process by avoiding unnecessary delays.

What Is Credentialing?

Before enrolling practitioners in health plans, the insurance companies independently credential providers. “Credentialing” is the systematic process of obtaining, verifying and evaluating the professional qualifications of a practitioner to provide services for a health care organization or for the plan’s members. The qualifications gathered and assessed include documented evidence of the practitioner’s licensure, education and training, relevant experience, and other specific criteria. Often peer references also are reviewed as part of the credentialing committee’s decision-making process. If the practitioner’s application for credentialing is approved, then that practitioner is credentialed with the health plan, which verifies to its members that the contracted professional has met the requirements of licensure, expertise, professional history and liability.

What Documentation Is Required?

The health plans require certain information to reach a credentialing decision based on assessment of the practitioner’s ability to deliver care. Though some variation exists between plans, in general the following is required for initial credentialing:

• Completed plan application
• National Provider Identifier (NPI)
• Current state license to practice
• Drug Enforcement Agency (DEA) registration, with current address and without restrictions
• School diploma
• Current curriculum vitae itemizing training and work history (with the month and year required for beginning and end of all employment, education and professional training, and gaps of six months or more explained)
• Board certification (unless provider finished residency within past five years)
• Malpractice claim history (via National Practitioner Data Bank, or NPDB)
• Limitations on scope of practice, state sanctions, restrictions on licensure, etc.
• Past and present hospital admitting privileges
• Creation of a Council for Affordable Quality Healthcare (CAQH) account, a database that collects and stores all of your information and documentation in one place that is accessible by those insurance plans that you authorize

Most of these qualifications will undergo primary source verification, which means the health plan will contact the original source or approved third party to confirm the accuracy and validity of the qualification. For example, the university granting the medical degree will be contacted to confirm your degree is not fraudulent. Additional information may be requested from the plan on a case-by-case basis.

Timeline for Completion

Allow ample time to complete the credentialing and enrollment process. Practitioners must be enrolled in the plans prior to providing services to plan members, so start the process as soon as you know you will be onboarding at a new location. The length of the enrollment process varies by plans, completeness and accuracy of the information you provide, and the existence of any special circumstances. Typically enrollment requires 90 days to complete, though the process could easily take between 30 and 180 days.

If you’re considering the move to another practice, contact Adaptive Medical Partners to help with that search. In the meantime, make sure you collect all of your qualifications in preparation for the health plan credentialing process that will take place when you begin that new position.