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Each healthcare provider who wants to provide their services must be credentialed. It is necessary for providers who want to bill insurance companies. Credentialing is like a license to ensure that the provider is fully qualified, trained, and has skills to meet the standards set by insurance companies. Credentialing also increases the credibility of healthcare providers and helps maintain high-quality care for patients. Without it, providers are not getting paid by insurance companies and obviously nobody wants to work for free. So, what exactly is medical credentialing? Why does it matter so much? Let’s discuss a step-by-step guide for providers on medical credentialing services.

What Is Medical Credentialing?

Medical credentialing is the process of verifying a healthcare provider’s qualifications like their education, training, licenses, board certifications, work history, malpractice claims (if any), and all the other credentials that show they’re legit. It is necessary for providers to show how insurance companies, hospitals, and healthcare networks make sure they’re letting qualified professionals into their systems. To serve patients and get reimbursement through insurance companies like Medicare and Medicaid, providers need to be credentialed. The main purpose of credentialing is to allow providers to provide care to their patients and get enrolled in an insurance network for reimbursement.

Why Is Credentialing So Important?

Credentialing is important as it helps to establish trust among patients and healthcare providers.

- No credentialing means no insurance payments. Even if you’re the best doctor in town, insurers won’t pay you unless they’ve given you the official credentialing paper.

- It keeps things legit. Credentialing protects patients and ensures that their providers have the proper background and are in good standing.

- It’s a legal requirement. For hospitals and most healthcare networks, credentialing isn’t optional but it’s mandatory.

You can’t skip this step if you want your practice to earn a stable income as well as gain a reputation in the healthcare field.

Understanding the Types of Medical Credentialing

Credentialing has various types depending on where you are in your career or what kind of setup you’re dealing with. Three types include: initial credentialing, re-credentialing, and provisional credentialing.

Initial Credentialing

Initial credentialing is what you go through when you're joining a new insurance network, hospital, or healthcare organization for the very first time. Here’s what they’ll usually check:

Re-Credentialing

If you’ve been credentialed and you’re already in-network then after a certain time, you need a re-credentialing. In this process they’ll check to see:

Provisional Credentialing

The most less known but useful type of credentialing is provisional credentialing. This is kind of like a fast pass that lets providers start seeing patients while their full credentialing application is still under review. It’s not available everywhere and each payer has different rules around it, but when it's offered, it can be very beneficial. Here’s how it usually works:

Step-by-Step: The Credentialing Process Demystified

Step-by-Step: The Credentialing Process Demystified

Step 1: Gather Your Info

First of all, you need to go through all your files and find every credential you’ve ever earned. Here’s what you’ll need:

Step 2: Enroll in CAQH (if you haven’t already)

CAQH (Council for Affordable Quality Healthcare) is like the central hub for provider data. Most insurance companies get your info from there so having an up-to-date CAQH profile is non-negotiable.

Here’s what to do:

Step 3: Choose Which Payers You Want to Work With

This is where you decide which insurance companies you want to be in-network with. Consider:

Step 4: Submit Your Applications

Submitting individual applications to each payer. Every insurance company has its own forms and requirements and some still use paper forms.

Expect to fill out:

Step 5: Wait and Follow Up (Like, A Lot)

Insurance companies aren’t known for their speed. After submitting your app, you’ll want to follow up every 2–3 weeks. Make sure:

Step 6: Complete Payer Contracts

Once you’re approved, the payer will send over a contract—this makes your participation official. Don’t just sign without reading! Look over:

Step 7: Keep Your Credentials Updated

You’re not done forever, instead credentialing is an ongoing process. Most payers require re-credentialing every 2-3 years and if any of your info changes like address, license, malpractice coverage, etc. you need to update it right away.

Set calendar reminders or use credentialing software to help stay on top of renewals and attestations.

Should You Do It Yourself or Outsource it?

Now the question arises here whether you do credentialing yourself or outsource it to a medical credentialing company. If you’re a solo provider just getting started and you’ve got the time then you can manage it by yourself. But if you have a very busy schedule and have a shortage of time then outsourcing can be a beneficial option. You can outsource your credentialing services to QuickPay Solution, the best medical billing company in the US. We provide complete credentialing services from paperwork to follow-ups. Our medical credentialing specialists know how to handle the complexities of credentialing.