Credentialing
Credentialing
Credentialing and provider enrollment play critical roles in the healthcare industry, particularly for healthcare providers seeking to participate in insurance networks and deliver services to patients. Here’s an overview of these processes.
Key steps in Credentialing:
- Initial Credentialing
- Application Submission
- Verification of credentials
- Privileging
- Verification of educational degrees and transcripts
- Validation of board certifications and specialty credentials.
- Evaluation of clinical competence, experience, and performance history
- Assessment of malpractice history and insurance coverage.
- Submission of enrollment applications to insurance companies and payers.
- Verification of provider licenses, and malpractice history.
- Contract negotiation and agreement on reimbursement rates and terms.
- Maintenance of provider information and updates to payer networks.
- Reimbursement and Revenue
- Revalidation & Re-Credentialing
- Contracting
- Review and Evaluation
In summary, credentialing and provider enrollment are essential processes in the healthcare industry, enabling healthcare providers to join insurance networks, receive reimbursement for services, and maintain high standards of quality and patient Safety.
Types of Provider credentialing
- Professional Group Practice
- Individual Practitioners
- Urgent Care Center
- Nurse Practitioners (NP)
- Physician Assistant (PA)
- Durable Medical Equipment Supplier (DME)
- Clinical Independent Laboratory
- Independent Diagnostic Testing Facility
- Clinical Nurse Specialist-Certified
- Home Health care
- Plastic Surgery
- Fully Licensed Psychologist
- Licensed Master Social Worker
- Podiatrist
- Independent Occupational Therapist
- Independent Physical Therapist
- Independent Speech Language Pathologist