Private Practice Credentialing Services

Private practice credentialing can be a complicated process and one that many professionals shy away from. While it is a worthy pursuit to pursue excellence in the medical community, there are compelling reasons why it must be undertaken by the profession’s members. Private practice credentialing is important for two major reasons. First, the process provides objective measurements of the practitioner’s knowledge and skills. Second, it provides the information needed for professional association development. Private practice associations protect their member physicians’ reputations and ensure that quality medical education and care are delivered to their members. Without access to a detailed history of the member’s performance, there is no way to verify that the physician has met standards of care or that the members are maintaining their membership in good standing. However, the history of each physician’s private practice is not static. In fact, documentation of all doctorates awarded, all patient contacts, all written articles, all minutes of meetings and other relevant information become part of the records of the physician’s private practice.

Prepare for Credentialing

Credentialing is a procedure that the insurance providers employ to validate your schooling, expertise, and work experience and to guarantee that you meet their quality standards for operating as an in-network physician on their panel. Insurance companies are obligated to create web based provider directories identifying all in-network carriers for their plans. These internet directories are commonly used by healthcare services consumers to identify physicians as well as other healthcare professionals who accept their insurance. The first stage in executing your new revenue cycle is to obtain certified and contracted with the private insurance that are important to your service region. Once finalized, consumers will be able to discover you as a participating provider on their panels for your specific specialty.

The process of “certification” or “provider enrollment” in an insurance plan actually consists of two parts. 1) Certification and 2) Contracting. The credentials step is when the insurance provider checks all your credentials and meets their network standards. This is when the company signs a contract for a participating provider that sets the terms and conditions of participation in reimbursing your claims in a network.

You will not receive a refund in-network without a qualified provider agreement. You may be able to sponsor the network as an out-of-network provider until your credential and contracting is complete, but your claims are not guaranteed. If your claim is allowed or not, it relies on whether your coverage has network advantages for the patient. Government health insurance like Medicare or Medicaid are not going to pay for out- of-network services.

Why Credentialing is important

Credentialing is important due to the following reasons

• Credentialing enhances patient confidence

• Credentialing prevents loss of income

• Credentialing reduces medical error risk

• Assists the health organization in the recruitment process

• Improves healthcare professionals’ reputation

• Credentialing – an approach that saves costs

• Increased reimbursements by third parties

• Offers the competitive advantage

Documents necessary for Credentialing

• Personal data such as email, street address, telephone, etc.

• Recent photograph in the margin signed and dated.

• Number of Medicaid.

• Number of Medicare.

• Copy of the supporting documents and confirmation letter of the National Provider Identifier (NPI#).

• UPON number.

• Number of Federal Tax ID

• Copies of federal Government DEA and current state registrations or certificates Controlled substances (s).

• Copy of the current license or passport of the driver.

• Standing Resident Card, Green Card or Status of Visa (if applicable) A copy of their green card must be provided for all non-US citizens.

• Copy of certificates of medical school and training, internship, residency and fellowships.

• EMC Current (CME activity for the past three years).

• Existing Board certificate copy, including issuing Board names and board certification/recertification dates.

Checklist for starting credentialing process

• Contact the network service provider to check its credential and receive a credential application. Most planning plans provide on their websites applications and information, such as Aetna.

• Take time to complete the application and include a list of every service site, sign, date, and copies of all the documentation required.

• Ensure that the information on your CAQH profile is up-to-date, including copied papers, such as license, insurance, board certificates, etc.

• Keep a copy of your request completed and submitted

• Make sure that your credential application is received from the insurance company and that you follow up regularly with the insurance network until your credentials are fully completed.

• Answer any further information requested by the insurance company

• Document all your follow-up activities during the credentials

• Review the nature of your needs as a network provider, the process for submitting claims, the cost schedule for your services, timely filing limits and all significant other elements of the contract

• Maintain copies of all applications for credentials and submitted contracts. Make sure your network contract has a final copy of it.


Now you’re a participating provider, you are ready to start paying for your health plan. Billing is yet another area of a revenue cycle that often works better for in-house outsourcing. Small practices can in particular gain a major benefit by outsourcing the duties with claims submission and reimbursement to a billing company.
Some of the most important things to remember when you start charging your services:

• Check patient advantages before treatment

• Collect copayment and/or co-insurance at treatment time

• Send your request within 24 hours of treatment

• Know how long the plan has to pay your claim under your contract and any claims that have not been paid within that period

• Post insurance payments promptly and account for any balance to the secondary payer (Assurance Company or patient).

• Retain copies of all EOBs for payments received

• Know what services are required for and obtain pre-authorization (pre-authorization is the responsibility of the provider)

• Keep up to schedule rules and billing procedures for your services

Benefits of Credentialing

• Private credentialing services are less expensive than most traditional methods of credentialing. They’re not time consuming either. All you need to do is find an agency in your area and let them know what you need. They will review your records with the proper agencies and submit your documentation to all the appropriate states and other entities. If you need information about a particular doctor, you just need to provide the name of the doctor and request that you be provided with the private practice credentialing documentation about that doctor. Within days, you’ll have the documentation you need to make sure that your patients get the care they need.

• In addition to saving money, you have complete control over what information you share and what information you don’t share. Unlike medical boards, insurance companies, and other thirdparty credentialing authorities, you have complete authority over what you do and what you don’t do in your private practice.

• When you use private practice credentialing services, you can be confident that your patients get the highest level of care. You can be confident that your reputation is not being damaged by submitting incomplete or false information or by allowing fraudulent activity to go unchecked.

• When you use private practice credentialing services, you can be confident that your patients get the highest level of care. You can be confident that your reputation is not being damaged by submitting incomplete or false information or by allowing fraudulent activity to go unchecked.

• Private practice credentialing is the only way to ensure that your private practices are providing the highest level of care for your patients.

• The decision to acquire a certificate is an essential step in your career. It shows not only basic understanding, but also your devotion to your career development. Professionals in health care choose to certify:

• For personal challenges and self-amelioration

• Improving wage opportunities and advances

• Demonstrate patients, physicians and payers skills, knowledge and abilities.

• To distinguish oneself by a commitment to lifetime learning and career development

• Health institutions and facilities value credentials because:

• This is a way of recruiting and retaining good health professionals

• Proves knowledge that health care professionals have complied with standard standards

• Increased evidence links certification with positive results


What steps must be taken to complete credentialing?

(1) You must submit an application in its entirety. If you do not complete the application completely or if additional information is required, you will be contacted by a representative from the House of Outsourcing. It is critical that you respond to those requests immediately, or your application will be unable to be processed. (2) House of Outsourcing conducts cross-checks with the “primary source” on specific data points. This includes your state licensing board, as well as your professional training/education. (3) Following source verification, your application is presented to a committee of your peers who will determine whether or not you meet our requirements. (4) If your application is accepted, you will receive an email with a welcome packet and guidelines.

How long will it take to process my application?

House of Outsourcing strives to complete credentialing applications in no more than 60 days. This process may take longer if you submit an incomplete application or omit requested attachments.

How frequently do providers require recertification?

Providers must recertify every three years, beginning with the date of their initial certification (unless their state has other requirements). A provider must successfully complete re-credentialing in order to remain a participating provider.

What occurs during the process of re-credentialing?

After approximately two and a half years on the network, you will be notified that it is time to renew your credentials. Your notification will include instructions specific to your specialty. If your application is on CAQH and is kept current, you may not even need to take any action at the time of re-credentialing.

What if the Credentialing Committee rejects my initial application for participation or my application for re-credentialing?

You may be given the opportunity to provide additional information and file an appeal, depending on the committee’s reasoning for its decision. Your denial or termination letter will outline your rights and the deadlines that must be followed.

Is it possible for me to submit a state application in the state in which I practice?

Yes. House of Outsourcing complies with all applicable state regulations.

What is a National Provider Identification Number (NPI) exactly, and how do I obtain one?

The term “NPI” refers to the National Provider Identification (NPI). If you have questions about obtaining an NPI, you should contact your state licensing board.

Is a Medicare number required for participation in House Of Outsourcing Care Solutions, LLC.

If you intend to provide services to Medicare beneficiaries, you must obtain a Medicare identification number. House of Outsourcing strongly recommends that you have one in order to participate in all health insurance plans. Certain health plans require this number in order for you to use any of their products.

What is a curriculum vita and is it required?

CV is an abbreviation for curriculum vitae. It’s similar to a resume in that it summarizes your educational background, work history, professional license, and any additional specialized training you’ve received. The House of Outsourcing does not require you to submit curriculum vitae. Rather than that, complete the application questions.

According to a letter I received, my credentialing application was denied due to a lack of information. What am I to do?

You must adhere to the provided instructions. Please contact the person who submitted the request if you have any questions. Please respond to these requests immediately to allow House of Outsourcing to continue processing your application.

Why am I required to send you the same information each time for re-credentialing?

If you have a CAQH application and have kept it current, House of outsourcing will obtain the information from CAQH. If you have not already done so, you must submit a CAQH application. After you have submitted the application, you must maintain accurate records. Additionally, if your clinic is accredited as an organization, a separate “group” credentialing application must be submitted.

I'm not sure why my access to the network was denied (or terminated).

You should have received a letter with a name and a phone number where you can obtain additional information.