Is Payor Enrollment Credentialing?

Credentialing is a term that can imply different processes, so it is important to know which process you are referring to when using the term credentialing. There are two main categories for credentialing: Primary Source Verification and Payor Enrollment. 1^st Credentialing only provides enrollment services to our clients.

Payor Enrollment is a term used to register providers and organizations into an insurance network so that they are considered “in-network”. There are two parts to the enrollment process: contracting and provider enrollment. Contracting is for the Business/Tax ID Number. This is the agreement that the medical organization signs with the insurance company and includes fee schedules, list of doctors, mid-levels, and any other provider who is eligible for enrollment on that Tax ID Number, as well as the locations of the clinic(s). Once the contract for the medical business is in place with the insurance, then the providers can be loaded on to the contract after they have been approved.

Medical providers of all types will go through a vetting process using the application submitted for that provider. This is called primary source credentialing. It is important to know that each provider must be sent to the insurance company individually even if there are several doctors who will be added to one contract (Tax ID Number).The reason for this is simple. Each person must be examined to ensure they meet the standards of the insurance company. The insurance company will be promoting the providers to their members via the provider directory, so they want to ensure the individuals are in good standing within their profession and they do not pose a threat for their members.

CAQH is also an important factor when looking to successfully enroll a provider. CAQH must be updated with all of the current information of the practice, locations, and any changes or updates to licenses and other requirements. Once the application is filed to the insurance company, they will access CAQH to compare the information in the CAQH portal to the application that was filed. If there are any discrepancies, the application will be denied.

The application for each insurance company is different. The same insurance company may even have different applications for every state and different types of applications for each professional license.

It’s important to note that there is no consistency in the applications, requirements, or processes between the insurance carriers. For this reason, using 1^st Credentialing to navigate the credentialing landscape for you ensures your provider applications and contract requests are completed accurately and timely.

Let us know if we can help you obtain in-network status!

To learn more about 1st Credentialing and the services we provide, please visit us at 1stCredentialing.com

At 1st Credentialing, we strive to make the Payor Enrollment process as simple and easy as possible for our clients. To learn more about 1st Credentialing, please visit our website or join our Facebook group, Credentialing Talk, where we discuss all the latest credentialing trends and news.