Getting paid for your services as a healthcare provider starts with becoming in network with insurance companies. You agree to provide the necessary medical documents to prove you are perfect to provide the services and accept the policies and reimbursement rates set by insurance carriers.

Credentialing in healthcare helps providers serve more patients and allows patients lower out-of-pocket costs. In this comprehensive guide, you will learn how to get in network with insurance companies along with the tips to efficiently complete the process. We’ll also answer some of the most common questions about insurance credentialing by the end of the guide.

How to Become In Network with Insurance Companies

Credentialing mistakes can lead to rejected claims, delay in revenue collections, costly compliance issues, and even contract terminations with insurance and billing companies, impacting practice’s financial stability and reputation. That’s why, it’s extremely important to follow the proper insurance credentialing process.

1. Have Your NPI, License and Certificates in Place
2. Get Medical Malpractice Insurance for Your Practice
3. Research Major Insurance Companies in Your Area
4. Register for CAQH Provider ID or the Alternative 
5. Audit the Application for Accuracy & Completeness
6. Contract With Insurance Carriers of Your Choice
7. Follow Up with Insurance Companies
8. Get In Network with Insurance Companies

1. Have Your NPI, License and Certificates in Place

The National Provider Identifier (NPI) is required by insurance companies and government programs like Medicare to process medical claims and payments. Alongside the NPI, providers must hold a valid state license and any required certifications, such as board certification, to practice legally and get in network.

• Visit the NPPES website and apply for your NPI.
• Check your state license and confirm if you need to update it.
• Verify you’ve all the necessary certifications required by insurance networks.

2. Get Medical Malpractice Insurance for Your Practice

Medical malpractice insurance provides coverage if a healthcare provider is sued for medical errors or negligence. Insurance companies require this coverage to ensure providers in their networks are financially protected in case of claims. It covers legal expenses and damages awarded to patients and other stakeholders.

• Research insurance providers specializing in medical malpractice coverage.
• Compare quotes and coverage options to find a policy that meets your needs.
• Ensure your policy meets or exceeds the minimum coverage limits.
• Obtain a copy of your malpractice insurance declaration page.
• Verify that your malpractice insurance complies with your insurance network.

3. Research Major Insurance Companies in Your Area

Researching major insurance companies ensures you align with providers widely accepted by patients in your area. Take these factors into consideration when deciding on the insurance companies:

• Geographic coverage (Insurance must be popular in your area).
• Patient demographics (Go for Medicare if you serve older patients).
• Insurance plan types (Popular in your area, e.g. HMOs, PPOs, and EPOs).
• Reimbursement rates (Compare to get the best rates).
• Administrative requirements (Choose insurance with streamlined process).

4. Register for CAQH Provider ID or the Alternative

The CAQH simplifies provider’s credentialing by allowing them to submit their credentials once for verification by multiple insurers. You can share all your educational documents, licensure, certifications, and work history at one place to ensure compliance with industry standards and regulations.

• Prepare necessary documents such as your CV, certifications, etc.
• Go to the CAQH ProView Platform
• Follow the instructions to register for your CAQH ID.

5. Audit the Application for Accuracy & Completeness

Carefully review each section of your CAQH application to verify that all information provided is accurate and up-to-date. Insurance companies rely on this information to assess your qualifications, so double-check for any missing fields or errors that could delay the credentialing process.

6. Contract With Insurance Carriers of Your Choice

After preparing your documents, researching the best insurance companies, and registering for CAQH ProView platform, you start the contracting process. Review the contract terms and fee schedules carefully to ensure they meet your practice’s needs and financial goals.

Pay attention to any specific requirements or restrictions outlined in the contract, such as emergency patient care obligations or administrative responsibilities. Complete all required forms accurately and thoroughly to avoid delays in the approval process.

• Reach out to the insurance companies you selected during your research.
• Request a copy of the provider contract and fee schedule.
• Carefully read through the contract terms and conditions.
• Understand reimbursement rates, patient care obligations, and more.
• Complete additional forms required by the insurance company.
• Double-check all forms for accuracy and completeness before submission.

7. Follow Up with Insurance Companies

Stay proactive by contacting each insurance company regularly to inquire about the status of your credentialing application. Follow up every two weeks to confirm receipt of your documents and to check on the progress of your application. This helps prevent applications from getting lost or delayed, ensuring timely processing and approval.

• Request confirmation via email or fax for your records.
• Inquire about the current status of your credentialing application.
• Ask if you need to provide any additional documents or information.
• Address delays or issues with your credentialing application.
• Keep detailed records of all communications with insurance companies.

8. Get In Network with Insurance Companies

Insurance companies will notify you of their decision to approve or deny your application. If approved, you will be added to their network of providers, allowing you to accept patients with their insurance coverage. If denied, the insurance company will provide reasons for the decision and may ask you to appeal or submit more documents.

Factors influencing the decision of insurance companies are the accuracy of your application, your qualifications, and adherence to their specific requirements.

• Upon approval, review the terms of the contract and fee schedule.
• Confirm your effective date of participation in their network.
• Update your PMS and notify staff of your new in-network status.
• Monitor communication for updates or changes from the insurance company.
• If denied, carefully review the reasons provided by the insurance company.
• Determine if an appeal process is available.
• Submit any necessary documentation if required.
• Contact the insurance company for clarification or further instructions if needed.

Practical Tips for Medical Insurance Credentialing

Navigating the insurance credentialing process can be complex! Let us share some essential tips to streamline your credentialing journey and maximize your chances of becoming an in-network provider.

1. Identify Your Target Payers and Markets

Target specific payers relevant to your practice’s geographical location and patient demographics to increase the chances of successful credentialing. BMB helps select first-class payers strategically and optimizes network access for you.

2. Understand Network Status

Determine if your desired networks are open or closed to new providers. Closed networks of your choice may still have avenues for entry through unique service offerings or strategic partnerships.

3. Showcase Unique Test Menu

Stand out by highlighting unique and proprietary tests in your healthcare service portfolio. Payers value offerings that differentiate your practice and add value to their insurance network.

4. Double-check & Follow Up

Double-check all your documents to confirm accuracy and completeness. Make sure you fulfill all the requirements by insurance companies. And keep following up for swift and easy approval by insurance networks.

5. Invest Quality and Accreditation

Invest in quality measures and accreditations such as CPCT or CCS-P. These credentials signal your commitment to high standards and patient safety, essential criteria for payer contracting.

6. Prepare Comprehensive Application Materials

Allocate sufficient time, typically 2 to 6 hours per application, for gathering required documents and completing forms accurately. Outsourcing this process can be cost-effective, allowing you to focus on patient care and practice growth.

7. Maintain Credentialing Compliance

Once credentialed, maintain compliance by regularly updating your CAQH profile and ensuring all licensing and insurance documentation remains current. Also, give timely responses to re-credentialing requests and adhere to network guidelines.

8. Partner with Credentialing Experts

Getting in network with insurance companies can be complex in the competitive healthcare landscape. It would be great to partner up with BMB, an experienced credentialing consultant, to expedite and optimize the credentialing process.

FAQs for Credentialing a Provider with Insurance Companies

Let us now answer some of the most frequently asked questions about getting in network with insurance companies.

What is insurance credentialing in healthcare?

Insurance credentialing is the process through which healthcare providers (such as doctors, dentists, therapists, etc.) get in network with insurance companies. The process verifies the provider’s qualifications, licenses, and practice history to ensure they meet the standards required to bill for the services and get reimbursement.

Is insurance credentialing hard?

Medical insurance credentialing is challenging due to its complexity and the detailed verification process. It involves submitting detailed documentation such as education credentials, licenses, certifications, malpractice insurance, and often requires multiple verifications and follow-ups with insurance companies.

What is the purpose of credentialing in healthcare?

The purpose of insurance credentialing in healthcare is quality assurance, regulatory compliance, patient safety, and insurance reimbursements. Credentialing is important for healthcare professionals because it helps them prove they are perfect to offer healthcare services covered in the insurance plans.

How to know if your insurance is in network?

To confirm if you’re credentialed with an insurance company, call each insurance company on your list to verify. Ask yourself if you have received a contract from an insurance company within the last three years.

What are types of credentialing in healthcare?

There are three primary types of credentialing in healthcare; physician’s credentialing, credentialing maintenance (or re-credentialing), and provider enrollment.

Physician Credentialing: Verifies qualifications and background of healthcare providers seeking new employment or contract opportunities.

Credentialing Maintenance: Ensures ongoing compliance with credentials and requirements throughout a provider’s career.

Provider Enrollment: Facilitates enrollment with insurance networks to accept reimbursement for services provided to insured patients.

What are the major benefits of credentialing in healthcare?

Insurance credentialing in healthcare boosts trust among patients, ensures adherence to industry standards, verifies provider’s qualification, and facilitates timely reimbursement for medical services provided to insured patients.

What are the three different types of credentials in healthcare?

In healthcare, the three primary types of credentials are certification, registration, and licensure.

Certification: Issued by professional organizations or certifying bodies to verify that a healthcare provider has achieved a specific level of skill or knowledge in a particular area of practice.

Registration: Often maintained by regulatory bodies or professional associations, indicating that a provider meets certain criteria to practice.

Licensure: Granted by state licensing boards, licensure verifies that a healthcare provider has met the minimum requirements to practice legally in a specific state.

What is a credentialing checklist?

A credentialing checklist is a comprehensive list of documents and information required from healthcare providers, including personal information, professional licenses, certifications, educational credentials, malpractice history, and other relevant details specific to the provider’s practice.

What is the difference between credentialing and enrollment in medical billing?

Credentialing and enrollment are different but interrelated in healthcare. Credentialing focuses on verifying a provider’s qualifications, education, training, and licensure. And enrollment involves a formal process of registering a provider with specific payers to establish reimbursement for services rendered to patients.

What does “in-network” mean?

“In-network” status indicates that a healthcare provider is credentialed with a specific insurance company and can submit claims for reimbursement at negotiated rates. This status reduces out-of-pocket costs and offers easy access to healthcare services covered by their insurance plan.

Why would credentialing be denied?

Credentialing denials can occur due to incomplete or incorrect information, expired or inadequate licenses required for practice, insufficient documentation, medical malpractice history, and for not meeting quality standards.

What are the most common mistakes I should avoid during insurance credentialing?

These are some of the most common mistakes you must avoid during credentialing that can lead to delays or denials:

• Incomplete applications with missing or inaccurate information.
• Failing to research and understand each insurer’s requirements.
• Forgetting to renew licenses, certifications, or malpractice insurance.
• Poor communication with insurers or delayed responses to inquiries.

Which documents are typically involved in credentialing?

Credentialing involves comprehensive documents to verify a healthcare provider’s qualifications and background.

These are some of the typical documents:

• Personal information (email, address, phone)
• National Provider Identifier (NPI) documentation
• Driver’s license
• Social Security card
• Recent signed photograph
• Medicaid and Medicare numbers
• UPON number
• Federal Tax ID number
• Immigration status documentation (if applicable)
• Current state medical licenses
• DEA and State Controlled Substance Registrations
• Medical school diploma and training certificates
• Board certifications and recertifications
• Surgical logs and hospital privileges documentation
• Delineation of Privileges Form
• Malpractice claims history and explanations
• Professional liability insurance certificate
• Case logs and insurance claims reports
• Curriculum Vitae (CV) with professional history
• Letters of recommendation
• ACLS/BLS certifications
• Residency diploma and military discharge record (if applicable)
• Immunization records and TB test results
• Examination scores and additional certifications
• ECFMG certificate (for foreign graduates)

Which credentialing body allows for a certification in billing and coding?

The American Academy of Professional Coders (AAPC), the American Health Information Management Association (AHIMA), and the Practice Management Institute (PMI) offer certifications to medical billers and coders.

American Academy of Professional Coders (AAPC) offers certifications like CPC (Certified Professional Coder), CPB (Certified Professional Biller), and others.

American Health Information Management Association (AHIMA) provides certifications such as CCS (Certified Coding Specialist) and others related to health information management.

Practice Management Institute (PMI) offers certifications in medical office management and billing, such as CMOM (Certified Medical Office Manager) and others.

Do all medical practices need insurance credentialing?

Yes, every medical practice that wants to bill insurance companies for services rendered must undergo credentialing. This requirement applies to all healthcare providers including hospitals, clinics, physicians, chiropractors, dentists, physical therapists, behavioral health therapists, occupational therapists, optometrists, and social workers.

How long does insurance credentialing take?

The credentialing process typically takes between 90 to 120 days on average. But the duration can vary based on factors such as the complexity of the provider’s practice, the responsiveness of the insurance companies, and the completeness of the submitted documentation. Some insurers may expedite the process, especially for urgent cases or certain specialties, while others may take longer to complete thorough reviews.

The timeframe for credentialing varies by insurer and type of credentialing:

• NPI application typically takes about 30 minutes.
• The CAQH application takes about 3 hours to complete online.
• Medicare and Medicaid usually take 40 to 60 days.
• State credentialing can take 90 to 150 days.
• Commercial insurance carriers take 60 to 90 days for credentialing and additional 30 days for contracting.

What are the biggest challenges to becoming credentialed with insurance companies?

The biggest challenges to becoming credentialed with insurance companies are market saturation, experience requirements, and time constraints. Working with leading credentialing consultants like BMB helps navigate these challenges effectively.

What are the timeframe requirements for credentialing?

Claims must typically be submitted within 30 to 90 days after service, depending on the state and insurer guidelines. Payers have 90 to 120 days to process claims, with the clock not resetting if a claim is denied. Timely credentialing is important to ensure uninterrupted billing and revenue flow.

Do I need to renew my practice’s insurance credentials?

Yes, you must renew your practice’s insurance credentials to maintain eligibility to bill insurers for services rendered. The process is called re-credentialing whose frequency varies among insurers, typically ranging from annually to every three years.

How do most practices manage credentialing?

Medical practices often designate a credentialing coordinator or outsource provider credentialing and enrollment needs to one of the best medical billing companies like BMB to optimize the process and maintain compliance. We gather required documents, ensure accuracy, and submit applications to first-class insurers, optimizing the entire provider’s credentialing. Get free consultation on how we can help make your credentialing process 2x easier and 3x faster.