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Physician Credentialing and Network Enrollment Health care credentialing is a verification process for academic, training and skills possessed by a health practitioner. Different tasks are undertaken during the process. These include identification of the medical school, verification of completion of educational training; confirm training such as internship, fellowship and residency. It involves going back to the primary source of these credentials. The state license board is contacted to confirm the issuance of the license. The licenses has to be checked whether it is active o there are restrictions applicable to it. They will have to contact the said medical school to verify the education credentials of the practitioner. The process can be lengthy or short depending on the items that have to verify and how complex they are. Physician credentialing is done to help health institutions allow practitioners to offer services in their campuses and for providers to participate in health insurance plans.
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On the other hand, the provider enrollment is processed by which a service provider requests to participate in a health insurance plan. The procedure starts by application to participate in a network/plan, submitting documents for credentialing process, other documents submission, submitting a license to a carrier and signing a contract. There might be some differentiations in requirements and procedure for different carriers. Several carriers trust CAQH as a central information. All service providers should have a complete up to date with CAQH for enrollment process. The health insurance firms take utilize the credentialing process to check for academic verification, licensing, training and other items that are required for a particular plan After the credentialing process has been through, the network offers a participating contract.
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Practice enrollment times depends on the payor. While some plans can be completed within 90 days; others will take up to 180 days. After submitting documents for enrollment, the provider should do a follow-up. This can be done using certified mail, emails, fax, documenting phone conversations with agents and others. There are some companies that help service providers with physician enrollment procedure to make it easy. The service provider only pays some fee to have this done. The client responsibility of application and following on the insurance companies is undertaken by the insurance firms. The benefits of working with these firms are that they save the physician on time. Their expertise dealing with insurance companies is also a big asset that physicians benefit from. Physician credentialing and provider enrollment should not be a nightmare for a service provider after updating their profile with CAQH system and working with facilitating companies. This will only work if the physician have a clean record.