Medical Credentialing

Medical credentialing is the process of applying to participate (become par, join the panel, become in network) with an insurance carrier. If the insurance company is accepting new providers in your specialty and your location, an application is completed by the provider and submitted to the insurance company. If accepted into the network, the provider will then be granted specific privileges with that insurance carrier.

Much information is requested as to schooling, licensing, experience, liability insurance coverage, languages spoken, etc on the application. These applications can be lengthy and vary greatly.

The major advantage of going through the process of credentialing and participating with the insurance company is that patients are more likely to use the services of a participating provider. When you participate you agree to accept a set rate of payment for your services and payment goes directly to the provider.  In order to treat a Medicare patient, you must enroll with Medicare even though you may choose to be non-participating. Here is more information on Medicare credentialing.

Some companies have their own applications, but what is becoming very popular with the insurance carriers is the universal CAQH credentialing process. Many companies now require that you are registered with CAQH where the insurance carrier can then examine your credentials online to determine if they will accept the provider to participate or to renew their contract.

The CAQH application eliminates the need to complete an application for each individual insurance company. The application can be completed either online or on paper. The purpose of the universal application is to eliminate the need for individual credentialing applications for each insurance company.

When a provider notifies an insurance company that he or she would like to apply to become participating, the insurance company can go to the CAQH application and find all the information they need without the provider completing yet another application.

You may still be required to fill out some paperwork for the individual insurance carriers, but it will be minimal. CAQH is the way of the future so it's a good idea to go ahead and complete the lengthy application for your credentialing.

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