Provider Credentialing Process and Requirements for Medicare and Medicaid

Assurance that the provider has been credentialed and enrolled by insurance payers and the Council for Affordable Quality Healthcare is the important step in ophthalmology and optometry medical and vision billing. In most cases, the provider credentialing process can take between 60 to 120 days. So it is important to plan early because one lapse during the credentialing process can lead to a delay, which usually results in starting the process all over again. If the provider isn’t properly credentialed or re-credentialed with the insurance company, the insurance payer will not reimburse the provider for services rendered.

Let’s analyze the details of provider credentialing and provider enrollment, and discuss important steps you need to take to ensure an efficient credentialing process.

Provider Credentialing for Medicare and Medicaid

Provider credentialing is the process of gathering and verifying a doctor’s credentials. Credentialing ensures that providers have the required licenses, certifications, and skills to care for patients properly.

Insurance plan credentialing is usually referred to as “getting on insurance panels.” Getting a provider credentialed can be challenging and time-consuming. While Medicare, DME (Durable Medical Equipment), and Medicaid provider credentialing can be done via their web portals, most insurance payers have their own credentialing process.

If you bill an insurance payer and the provider is not credentialed with the payer, this will lead to denied claims. Once the insurance payer denies the claim, most set time limits on re-submitting a claim. If a patient has secondary insurance, you can run into even more issues as the longer you wait, the more likely you won’t recover the maximum amount (or any) from the insurance payer.

What is CAQH ProView?

CAQH ProView is an online “data-collection” credentialing solution that allows ophthalmologists, optometrists, and other healthcare providers to enter provider data into its secure central database. CAQH gathers information about the provider, so it is available for third-party payers to access.

Most medical and vision plans use the CAQH ProView in their credentialing process except for Medicare and Medicaid. There is no cost for the provider to register with CAQH ProView. But the insurance company must notify CAQH to invite the provider to join CAQH to create, update, and maintain their directory information before the provider can upload their information into CAQH ProView,

What is Provider Enrollment?

Provider enrollment is the process of enrolling a provider with commercial or government health insurance plans to which the provider can be reimbursed for the services rendered to patients.

Tip for Medicare Provider Enrollment:

Refer to the Medicare enrollment and certification website for instructions on how to access the PECOS Medicare enrollment management system, becoming a Medicare provider or supplier, finding your taxonomy code, renewing your enrollment, ordering and certifying, enrolling as a DMEPOS supplier, and more.

Critical Steps for Credentialing a Provider

1. Make a list and collect all information you need for provider credentialing applications like professional licenses, work history, certifications, bank statements, and more.
2. Get the provider’s National Provider Identifier, Federal Tax ID, and Practice EIN (this must match what is listed on the provider’s W-9 form).
3. Register the provider with CAQH and obtain their CAQH ID. Make sure CAQH has a valid W-9 and malpractice certificate for the provider. Confirm that the dates of employment and education are in the “month/year” format. If you don’t post valid dates, CAQH will reject the application.
4. Confirm if you need the original handwritten signature of the provider to process the credentialing request.
5. Complete and submit a series of applications with each insurance payer.
6. After completing the initial credentialing review, always get a “reference number” from the insurance payer and document this in your credentialing tracking records.
7. Follow-up with insurance payers on the provider’s credentialing application status—they are famous for not calling back if something is missing from the application.
8. Make sure that your billing system is updated with payer information. Review the fee schedule before you sign a credentialing contract with an insurance payer.
9. Keep copies of all credentialing applications and contracts you submit, as well as credentialing and enrollment letters you receive from the insurance payer.

Why you required a Reliable Provider Credentialing and Enrollment Process

The top revenue cycle management partner helps you explain the provider credentialing and enrollment process by reviewing and gathering documentation to ascertain the provider’s participation in the health plan.

A reliable and efficient credentialing and enrollment service eliminates the fatigue of submitting and tracking credentialing and enrollment applications based on the insurance plan requirements.

ZEE Medical billing consultants are here to help with full-service revenue cycle management solutions.