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what is credentialing in medical billing

An Insider’s Guide On What Is Credentialing In Medical Billing

Medical billing is an intricate process, running on rules and regulations. Without proper management, every billing task can deviate from government-established policies and thus healthcare facilities may face severe legal consequences. One aspect of this regulation is credentialing. So what is credentialing in medical billing?

Just like a healthcare professional needs to confirm their degree and skills to begin treating humans, other areas like the facility’s rendered services should be verified to provide health treatments. Credentialing is what ensures the quality of all doctors, their supplies, and the hospital’s performance.

As a layman, you might be new to this term. So here we will dive deep into the process of credentialing and why this is a crucial step in building your reputation.

What Is Credentialing In Medical Billing?

a kid with mask

In simple words, when a new healthcare facility is established, it must show its credibility to responsible authorities. This makes sure they are eligible enough to provide their services and thus a patient’s life is in safe hands.

Imagine, going to a hospital but you don’t know how qualified their doctors are. Risky right? You wouldn’t trust them in the case of your health. So when you ask what is credentialing in medical billing, the simple answer is to establish trust and ensure a patient that they are going to get safe treatments.

A healthcare facility can conduct credentialing on themselves as well as through specialized companies. When conducting in-house credentialing, they are required to follow specific steps which we will discuss later. If a company is hired, then the firm is responsible to conduct processes and handle all the tasks to provide complete credibility.

No healthcare facility can run its operations and begin medical billing after just starting out. They must show their credibility and satisfy legal and industrial regulations. Thanks to this method, today almost all hospitals and clinics are trustworthy now.

What Needs To Be Credentialed?

a healthcare professional

When we talk about credentialing, many things might come to your mind. You may think do only doctors verify themselves or just medical supplies? But in reality, many other aspects of healthcare are also verified to ensure quality services as a whole. So here we have discussed common credentialing targets that every facility works on.

Healthcare Professionals

They are the basic part of the healthcare industry. They directly work on a patient’s wellbeing, so ensuring their qualification and verification is essential.

Health Facilities

Not only humans but buildings are also verified. By this, we mean the eligibility of any hospital, clinic, or other facility is ensured. This enables them to keep providing their services by staying within legal regulations.

Medical Labs

Besides hospitals and staff, healthcare laboratories must undergo credentialing to ensure accurate test results and equipment utilization.


Since health supplies also make up a big part of healthcare, all the supplied equipment and devices are verified. It helps confirm the use of clean and hygienic medical supplies i.e syringes to protect patients from any potential health disease.

Dive Deep into Nurse Credentialing


Not only hospitals but also pharmacies are credentialed. Medicines are what have a direct impact on a patient. A low-quality medicine may worsen the disease. So here pharmacies are considered a must to show their credibility.

Insurance Providers

Here it doesn’t mean that insurance companies undergo credentialing. Instead, the healthcare providers who want to treat insured patients go through this process. Insurance companies initiate this process. They want to make sure their clients or patients receive quality care from a specific facility. 

Also, insurance credentialing allows you to bill patients based on their insurance. It’s just a ticket to create an establishment with insurance companies and receive bills from them on behalf of the patients.

Process Of Credentialing

person signing document

After knowing what is credentialing in medical billing, the next question you might ask is how they credential themselves. Every healthcare facility and staff needs to go through this process. But what are the steps in the process? Here are these steps mentioned in short to make you understand how this thing works.

Preparation Stage

This is a pre-authorization stage where you make some advance preparations. Here the one who needs to be credentialed gathers the necessary documents. It includes educational credentials, qualification certificates, facility licenses, and many others. They also gather close contacts or colleagues to make the process credible.

Application Submission 

Then they fill out the forms provided by the insurance companies or credentialing firms. Here all the details about the facility are mentioned along with supporting documents.


Here the credentialing organizations communicate with your mentioned qualification institutes and firms you have been associated with. This step ensures verification and builds trust.

Background Check

Background check is a crucial step in credentialing. They verify your history to find out any criminal record or malpractice case your facility conducted. It helps the company ensure belief in your healthcare services and safety for patients.

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    References And Recommendations

    They also reach the peer and colleague references you mentioned in the forms. Your associations may tell you better about your facility and experiences working with you. If your collaborations have been uncomplicated, then your peer’s remarks will satisfy the credentialing and insurance firms.

    Committee Review

    Then the process enters the crucial stage. Here a committee is hosted by the credentialing company. This meeting is based on healthcare professionals, legal persons, and administrators. They then review your applications, documents, and their research work about your facility.

    Decision And Notification

    This is the deciding stage, whether you are verified or not. But don’t worry, if you have provided accurate documents, then the answer will be YES. In that case, you will be notified and allowed to provide your services without any worries. However, in case of dissatisfaction, you will receive a big NO. But you always have a chance to improve and appeal, so worry not.


    To mark the process complete, documentation is conducted and the parties involved sign their agreement.

    On-going Monitoring

    If you think credentialing is a one-time operation, you are wrong. This is an ongoing process. Just like a product has an expiry date, your credentialing license also has a date that needs to be renewed. It helps them make sure you keep providing quality care and don’t deviate from your terms.

    Credibility Matters!

    Though the healthcare industry is filled with intricate processes, knowing what is credentialing in medical billing and how it is done is crucial in understanding a base process upon which every other task of billing stands. 

    Without verification, you won’t be able to show credibility to your patients and gain their trust. So make sure you go through this process, be you a healthcare professional, you own a facility or you supply medicines and equipment.

    Healthcare should be based on love and care. Showing these traits will level up your business and fix the health of the patient as well.

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