Posted By Monique Dever On October 20, 2015

Credentialing Made Easier for Local Health Departments

First, let’s be clear about credentialing. You do not credential facilities, you credential providers, but it does benefit the facility in terms of revenue and reputation. But let’s face it, many health departments are not billing as much or as efficiently as they should be. Often times, physicians, especially new physicians, are only partially credentialed, leaving a lot of billing potential untouched and a lot of potential revenue left behind. Does this sound familiar? It doesn’t have to.

Credentialing is a means of verifying and documenting the qualifications of providers and checking their background and legitimacy; it testifies to the levels of professional competence and conduct of each provider, which enhances the image of the department. It also offers patients the confidence that they are getting professional care.

Insurance credentialing means you become affiliated with the insurance company so that you can accept third party reimbursements, which is a benefit for underfunded local health departments in terms of maximizing revenue streams.

In order to become a participating provider for an insurance company, you need to first credential your individual provider(s). The second step is contracting your facility. It is not a difficult process and can be submitted and maintained online through the Counseling for Affordable Quality Healthcare (CAQH).

Each state has adopted a universal uniform application which takes the place of many applications if done per payer. CAQH is a universal provider data source. It is a Washington, DC-based non-profit organization that collaborates with healthcare providers, trade associations, and insurers and has over one million providers. CAQH will keep your application on file with multiple payers that identify and use this web site. Some of the participating organizations on the CAQH network include:

  • United Healthcare
  • Blue Cross Blue Shield
  • Aetna
  • Medcost
  • GreatWest
  • WellPoint
  • And more…

CAQH saves your facility time and money and keeps information current. It saves time by eliminating the need to fill out multiple, redundant and time-consuming forms. It saves money because not only is the application entirely free to providers, it cuts down on your administrative resources at your practice. There is no need to fill out information forms over and over again. It keeps your information up to date through notifications and alerts that sensitive information is expiring, such as licenses, certifications or insurance.

In order to participate there are a few steps you’ll need to take. You must contact the insurance company you want to become credentialed (e.g BCBSNC). From there, the insurance company will contact CAQH on your behalf. CAQH will then send you a unique provider number that you will use to establish a log in and password.

Once you are logged in you will complete the application and follow the guided process through each step by preparing the application, asking certain questions, and performing an audit on your answers given. After the audit, fix any incorrect information and then authorize the payer to receive your application. Once you attest that your information is correct, you will fill out the supporting documentation and electronically attach it to your application or via fax cover sheet.

Be warned, the fax cover sheet can be complicated so read all documentation carefully. If it is not done correctly, it will be discarded and you will not receive an update.

To join a network simply call the insurance company direct to begin the process. Examples of some key providers and links are:

Once the credentialing has been completed, the insurance provider will send you a network agreement, or contract. Simply sign it and return it to the insurance company. You are now ready to receive your in network reimbursements!

Enjoying the benefits of credentialing is not a one-time process. Re-credentialing must be done for each payer, every 3-5 years. For re-credentialing with CAQH, you simply need to update your provider information, re-authorize the insurance to re-credential, and then re-attest. It is that easy.

About Monique Dever

Monique integrates research and networking with her passion for health and well-being to provide important, up-to-date news, resources and current events to the public health communities. She is the Marketing Executive for Patagonia Health, an Electronic Health Records (EHR) software company focused on the public health sector.