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Informative Guide On Credentialing In Healthcare

Where other services in the country should satisfy qualification standards, the healthcare industry specifically needs to be thoroughly verified. This can be possible by conducting a number of verification processes, one of which is credentialing.

Since the term itself defines what it means, credentialing is the process of verification of a certain health service or provider in order to make it comply with quality standards. Credentialing may mean different in other industries, but in the medical industry, it is the process of executing careful verification of health care providers.

Let’s dive into the guide on credentialing, where you will know its basics and process.

Credentialing In Simple Words

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The term might frighten you whenever you read it, but in reality, its definition is much easier to understand. Let’s break down credentialing into uncomplicated definition. 

Any health practitioners or service providers including clinics, counseling offices, dentists, physicians, therapists, social workers, and optometrist’s offices, who wish to establish their facility and bill their patients by using patient’s insurance coverage, they must pass from a process known as credentialing. 

Insurance companies make sure those who are charging them directly for their patient’s bills are verified health practitioners. That’s why they conduct the entire process of credentialing to ensure their bills are going to the proper place.

The process involves 2 phases: the Credentialing stage and the Contract stage. 

At first, when you show your interest in doing bill collaboration with an insurance company, they start the credentialing process. They will send a panel that will conduct thorough research on whether you meet insurance panel requirements or not. They may also check education and employment background.

When the insurance panel has verified your qualifications, they will send the health practice the contract. Meanwhile, the insurance payer and practice will discuss the in-network contract. If this contract is offered, the practice will be more likely to pay a fee after which they can bill the insurance payer for specific CPT codes.

Credentialing Process

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Usually, 90 days is the period under which a physician is credentialed and approved to provide its services. But sometimes record inaccuracies or lack of supported documents may lengthen the process further.

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However, the Credentials verification organization (CVO) is the one that reviews and approves an application. Here is the process of credentialing:

  1. First, compile the details of the health service provider. Collect its:
  • Accurate license
  • Work history
  • Certificates
  • W-9 forms
  • Bank details and such
  1. Get National Provider Identification (NPI), federal tax ID, and practice EIN from the W-9 form.
  1. Obtain the provider’s CAQH ID to register them with your health facility. Re-check the dates and months of the provider’s malpractice certificate and W-9, it must be identical to CAQH. Otherwise inaccurate dates may lead to quick application rejection.
  1. It is also essential to verify if your credentialing application requires to have handwritten signatures.
  1. There will be multiple insurance payers to submit applications, as patients have their insurance packages in different organizations. After preparing the provider’s application, send it to numerous insurance companies.
  1. After the initial credentialing process, get a reference number from insurance payers and save it in your records.
  1. Keep a regular follow-up of the provider’s credentialing application. Sometimes you forget a few details to transmit. But it is easy to contact them by telephone and ask about the application progress, which can help you know its status.
  1. You must also make sure to check the insurance payer’s correct info in your facility’s system. If your application is accepted, you will be required to sign a contract. But be careful before signing and check the fee structure properly.
  1. Preserve the soft copies of the documents used during credentialing and contains the details of the contract.

Benefits Offered By Credentialing

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Ever wonder why health facilities prefer credentialing, here are some reasons for that:

Establishes Credibility

Not only insurance companies, but credentialing is also important to build trust with patients. They are more likely to prefer a verified health practice and a physician that has a proven record of their qualification. Of course, a non-qualified one may be unable to gain patients’ trust, whereas patients too will not rely on them regarding their health concerns.

Maximizes Revenue

Credentialing involves a contract between the insurance payer and health practice, on the basis of which the practice becomes eligible to bill that insurance company. Without proving your credibility you can’t be able to secure revenue from insurance payers and could miss a huge revenue portion.

From the perspective of insurance payers likewise, they won’t pay for the claims of those health practices that are not qualified enough. 

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    Reduces Medical Risks

    Many of the deaths that occur in the United States are due to medical uncertainties. That means a lack of medical facilities or qualified services. The reason might be:

    • Limited patient medical reports
    • Hundreds of facilities (with only a few professionals)
    • Lack of communication
    • Physician prescription errors
    • Negative drug impacts
    • Clinics with no staff in undeveloped areas
    • Poor patient workflow management

    While all these things contribute to keeping away patients from getting health treatments from new facilities, credentialing can be the only way to prove their trustworthiness.

    Protection From Lawsuits

    If you run a health facility containing many physicians, you must make sure to verify their services before hiring. As if any blunder occurred during the treatment from a physician working at your clinic or hospital, you could face legal consequences.

    To avoid this you must keep an updated record of your physicians at hand.

    Reputation Growth

    Patients these days have become digital-savvy, they tend to research a health facility on the Internet before considering any medical treatment. That means you must maintain a positive online reputation to attract more business.

    For this, credentialing may help you. It makes a health facility and its physician qualified, with the help of which people will find them on the internet and consider them regarding their health issues.


    With the help of your detailed guide on medical credentialing, you are now able to understand the topic more thoroughly. If you are a physician trying to get associated with a healthcare facility or if you are a hospital that wants to build its reputation, credentialing may help you stand solid in the ground.

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