Medical and CAQH Credentialing explained. The benefits of CAQH healthcare credentialing explained.
What is Credentialing
Medical or healthcare credentialing is the process involved of requesting to participate in a health insurance providers network - or to be contracted with the insurer.
Healthcare providers have to apply to and be accepted by the insurance company to qualify for benefits or privileges of being associated with or a “network provider” for that insurance carrier.
The application process for credentialing is a very involved process which requires a lot of detailed information on the provider such as where they received training and education, background and experience, etc. The processing of applying can be quite involved and time consuming. Each insurance carrier’s application process is different.
Benefit of Credentialing
If you’ve every tried to locate a doctor or specialist, one of the important factors in selecting one is if they are a participant in your insurance providers plan or network. If they do not, your insurance usually doesn’t pay as much - and your claims are paid as “out of network”. This typically means you have a higher co-insurance and/or co-pay amount.
A patient is much more likely to select a provider who participates in their insurer's network. The providers that participate in the insurance companies network agree to accept the contracted payments for their services. This is also true for Medicare - they also have a credentialing application process. Even if you choose not to participate, a provider still has to enroll with Medicare to treat Medicare patients.
CAQH Provider Credentialing
As a provider, wouldn’t it be great if you could make one application that would be accepted by all insurance companies. That way you only have to endure the pain of the application process once. This is the advantage of credentialing through CAQH.
CAQH (The Council for Affordable Quality Healthcare, Inc.) is a nonprofit alliance of health insurance plans and healthcare trade associations dedicated to simplifying healthcare administration. CAQH was established to streamline the paperwork required for healthcare providers and their employees.
CAQH Universal Provider Datasource (UPD) is a service that provides establishes the standards for credentialing healthcare providers. This service acts as a clearinghouse for insurance carriers and is free to providers. The providers information is input into the CAQH credentialing database and can be accessed by all of the participating insurance companies.
While some insurers still maintain their own application process, most participate in the CAQH credentialing process - and many require it. This simplifies the process and allows the insurance company to examine the providers CAQH existing credentials without having to go through another lengthly application process.
CAQH medical credentialing eliminates having to go through the application process with each insurance company. It’s free and can be completed online. If a provider desires to participate in the insurance providers network, the insurer can access the providers CAQH credential application. Some insurance companies may require additional information, but this is usually minimal.
Due to it’s complexity and thoroughness, the process of applying for credentialing can be confusing and overwhelming. There are consultants who specialize in CAQH credentialing and can assist a provider or their staff in the process. If you haven’t done this before or are intimidated by the forms, you may considering outsourcing this function as it can be well worth it.
Because a providers information may change, every four months the provider is automatically sent a reminder to reaffirm the accuracy of their information. This can be done easily and quickly either online or through their toll free number. Many of the health plans the provider is associated with use the CAQH credentialing database to update the provider records.
How long does the credentialing process take? Typically within 30 days of receipt of all the application and supporting documentation.
Providers who want to participate in the CAQH healthcare credentialing process and their UPD database must have a contractual agreement with an insurance plan to take advantage of CAQH. Once included in the UPD, the provider is invited to participate and sent an ID number necessary for accessing the UPD database and entering all of the providers info online.
In order to submit claims to Medicare for reimbursement, a provider must be credentialed - whether they are a participating or non-participating provider. An individual provider must complete the 855I enrollment form - approximately 29 pages. Here’s more detail on Medicare Enrollment Forms.
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