Insurance Credentialing – How to Get Credentialed with Insurance Companies

Credentialing is the process of getting authorized by insurance companies to provide services to their members. It involves submitting detailed information about your qualifications, practice, and compliance with regulations. This step is crucial to becoming an in-network provider and being able to bill insurance companies for services rendered.

Insurance Credentialing

Steps for Credentialing: #1 Gather Necessary Documents

  • Medical License: Proof of your authorization to practice in your state.
  • NPI Number: Get your National Provider Identity (NPI). NPIs identify you when filing an insurance claim (HIPAA requirement). Get your NPI at: https://www.cms.gov/medicare/regulations-guidance/administrative-simplification/how-apply
  • Malpractice Insurance: Evidence of professional liability insurance coverage.
  • Board Certification: Certification from your relevant professional board.
  • Curriculum Vitae (CV)/Resume: A detailed resume outlining your education, training, work experience, and other relevant qualifications.
  • Completed Application Forms: Forms required by each insurance company, which often include detailed questions about your practice and professional history.

Steps for Credentialing: #2 Submit Application

  • Complete and submit the credentialing application to the insurance company along with all required documentation.
  • This can often be done online through the insurance company’s provider portal or a credentialing service.

Steps for Credentialing: #3 Follow Up

  • Credentialing can take several months, so it’s important to start the process early and follow up regularly with the insurance companies to check on the status of your application.

Detailed Credentialing Steps

  1. Prepare Documents:
    • Medical License: Ensure you have a valid and up-to-date medical license.
    • Malpractice Insurance: Obtain a malpractice insurance policy and have proof of coverage.
    • Curriculum Vitae (CV)/Resume: Keep an updated CV detailing your education, training, work history, and any certifications.
    • Board Certification: Provide proof of board certification if applicable.
    • DEA Certificate: If you prescribe controlled substances, you will need a DEA (Drug Enforcement Administration) certificate.
    • NPI Number: Make sure you have a National Provider Identifier (NPI) number.
  2. Choose Insurance Companies:
    • Decide which insurance companies you want to work with (e.g., Aetna, Medicare).
    • Research the requirements and processes for each company.
  3. Application Process:
    • Contact Insurance Companies: Reach out to the insurance companies you want to be credentialed with. This can often be done through their provider relations department or website.
    • Complete Applications: Fill out the credentialing applications for each insurance company. This may include providing detailed information about your practice, education, experience, and more.
  4. Provider Enrollment Forms:
    • CAQH ProView: Many insurance companies use the CAQH (Council for Affordable Quality Healthcare) ProView service for credentialing. Create a profile on CAQH ProView and complete the required information: https://proview.caqh.org
    • Individual Insurer Forms: Some insurers may have their own forms and processes.
  5. Submit Applications:
    • Ensure all forms and documents are thoroughly completed and submit them to the insurance companies.
  6. Follow-Up:
    • Regularly follow up with the insurance companies to check the status of your application. Credentialing can take several weeks to a few months.
  7. Site Visit (if required):
    • Some insurance companies may require a site visit to verify your practice location and facilities.
  8. Contracting:
    • Once you are approved, you will receive a contract from the insurance company. Review the contract carefully, paying attention to reimbursement rates, billing procedures, and any other terms.
    • Negotiate Terms (if necessary): Don’t hesitate to negotiate terms that are not favorable to your practice.
  9. Sign Contract:
    • Once you are satisfied with the contract terms, sign the contract and return it to the insurance company.
  10. Billing and Claims Setup:
    • After credentialing, set up your billing system to handle claims submissions to the new insurance companies. Ensure your staff is trained in the specific billing requirements of each insurer.

Understanding and Obtaining NPI Type 1 & Type 2

The National Provider Identifier (NPI) is a unique identification number for covered healthcare providers. It is essential for billing and claims submission. There are two types of NPIs: Type 1 and Type 2

Importance of NPI Type 1 & Type 2

  1. NPI Type 1: Individual Provider
    • Definition: Assigned to individual healthcare providers (e.g., physicians, dentists, nurse practitioners).
    • Importance: Used for identifying individual providers in transactions such as billing and prescribing.
    • Use Case: Dr. Smith, a primary care physician, uses NPI Type 1 on all claims submitted for services rendered by him personally.
  2. NPI Type 2: Organizational Provider
    • Definition: Assigned to healthcare organizations (e.g., hospitals, group practices, nursing homes).
    • Importance: Used for identifying healthcare organizations in transactions.
    • Use Case: ABC Medical Group, a multi-specialty practice, uses NPI Type 2 for claims submitted by the group as a whole.

How to Obtain NPI Type 1 & Type 2

Steps to Obtain NPI Type 1 (Individual Provider)

  1. Prepare Required Information:
    • Personal information (name, date of birth, social security number).
    • Practice location and contact information.
    • Taxonomy (specialty) information.
  2. Create an Account on NPPES:
    • Go to the NPPES (National Plan and Provider Enumeration System): https://nppes.cms.hhs.gov
    • Click on “Create or Manage an Account.”
  3. Complete the Application:
    • Follow the prompts to complete the NPI Type 1 application.
    • Provide all required information and double-check for accuracy.
  4. Submit the Application:
    • After completing the form, submit the application.
    • You will receive a confirmation and tracking number.
  5. Receive NPI Number:
    • Typically, you will receive your NPI Type 1 number within 10 business days via email.

4.3 Steps to Obtain NPI Type 2 (Organizational Provider)

  1. Prepare Required Information:
    • Organization’s legal business name.
    • Employer Identification Number (EIN).
    • Practice location and contact information.
    • Authorized official’s personal information (name, title, phone number).
  2. Create an Account on NPPES:
    • Go to the NPPES website.
    • Click on “Create or Manage an Account.”
  3. Complete the Application:
    • Choose the option for NPI Type 2.
    • Follow the prompts to complete the NPI Type 2 application.
    • Provide all required information about the organization.
  4. Submit the Application:
    • After completing the form, submit the application.
    • You will receive a confirmation and tracking number.
  5. Receive NPI Number:
    • Typically, you will receive your NPI Type 2 number within 10 business days via email.

Example Applications

Example NPI Type 1 Application Information:

  • Name: John Smith
  • Date of Birth: 01/01/1970
  • Social Security Number: 123-45-6789
  • Practice Address: 123 Main Street, Suite 100, Anytown, USA
  • Phone Number: (555) 123-4567
  • Taxonomy Code: 207Q00000X (Family Medicine)

Example NPI Type 2 Application Information:

  • Legal Business Name: ABC Medical Group
  • EIN: 12-3456789
  • Practice Address: 456 Elm Street, Anytown, USA
  • Phone Number: (555) 987-6543
  • Authorized Official Name: Jane Doe
  • Authorized Official Title: CEO
  • Authorized Official Phone Number: (555) 987-6543

Private Practice Business Structure

We suggest creating an LLC with an EIN (tax ID) and using the NPI Type 2 (Organizational Provider) for your private practice.

For our LLC, we purchase liability insurance via ioausa.com. We purchase Malpractice Insurance via proliability.com.

Apply for an Employer Identification Number (EIN) online: https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online

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Insurance Credentialing

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All content contains personal experiences and is not intended to provide medical advice. For personalized medical guidance, please consult with a qualified healthcare professional. The author and associated entities assume no liability for actions taken based on the content herein.