Credentialing Process Overview
"Advocate. Market. Elevate."

The following is a generalized overview of the credentialing process:

  • Complete all initial and re-credentialing applications;
  • Mail or electronically submit applications with tracking number to third party payers;
  • Follow-up with payer to ensure receipt of application;
  • Maintain consistent communication through the credentialing process with payers;
  • Report to clients for each entity at client-determined intervals; and
  • Communicate the confirmation of participation/privileges to clients.

By outsourcing your credentialing process, you will free up your staff from using a large amount of time filling out unmanageable credentialing or re-credentialing applications. We will make sure you will never miss another filing or recredentialing deadline.

Health Plan Credentialing Process – An Overview:

Step 1 Compile documentation and information from provider

Step 2 Submit physician application and documentation to health plan

Step 3 Health plan conducts primary source verification

  • All licenses (state, DEA, CDS)
  • Education, training (internship, residency, fellowship)
  • Hospital staff privileges (current and previous)
  • Malpractice insurance coverage (for at least 5 years)
  • Claim(s) history (for at least 10 years)
  • Work history (since finishing training)
  • Any sanctions with Medicare or MediCaid
Step 4 Health plan’s credentials committee reviews and approves

Step 5 If required, health plan conducts site visit to facility(s)

Step 6 Health plan adds provider locations(s) and tax ID numbers to its system

Step 7 Provider joins health plan network

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