Credentialing Process

• Credentialing is the process of assessing and confirming the qualifications of a licensed or certified healthcare practitioner.

• Credentialing is an essential process that healthcare organizations and practices must perform to ensure those proving services are qualified to do so.

• There are 2 types of credentialing:

    1. Healthcare facility/Hospital Credentialing

    2. Health Plan Credentialing

    1. Healthcare facility/Hospital Credentialing:

• When a doctor wants to work for a facility/hospital, he/she needs to submit all the relevant documents to the facility/hospital. All the documents will be verified by the authorized team of the facility/hospital and after successful verification, the doctor will get credentialed with the facility/hospital to work.

    2. Health Plan Credentialing:

• Similar to Facility/Hospital credentialing, to get credentialed with the health plan, the provider needs to submit the relevant documents to the health plan and after verification, the provider gets credentials with the health plan.

• The credentialing process makes the provider trustworthy and it expands the provider's reach to get more patients.

• If the provider is not credentialed with the health plan, he/she will consider an out-of-network provider which will result in fewer patient visits as out-of-pocket expenses will be high.

• The provider also needs to renew their contract and license timely.

• If the provider is not credentialed properly with facility or insurance then we can get below denials from insurance,

• B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service.

• 185: The rendering provider is not eligible to perform the service billed.

• 183: The referring provider is not eligible to refer the service billed.

• 184: The prescribing/ordering provider is not eligible to prescribe/order the service billed.

• 8: The procedure code is inconsistent with the provider type/specialty (taxonomy).

• In addition to the above denials, when we call on denial B7 or 185, sometimes the rep says that the claim is denied as the provider is not enrolled/credentialed with the group provider. The reason is that the doctor is not credentialed with the facility/group.