When provider want to participate in health plan networks to treat insured patients and receive in-network and out of network reimbursement provider must go through a credentialing and contracting process with each health plan. This process is referred to as “Provider Enrollment & Credentialing“. The process varies by carrier with some initiating the process with a phone call, others have standard forms to be completed, and some require online credentialing applications be completed. There has been some standardization of the process through CAQH, but the process still requires manual intervention and consistent follow up to ensure it is done correctly and timely.
- Application Evaluation: Completing required documentation and identifying exceptions.
- Primary Source Documentation: Verify practitioner/ facility information from physicians.
- Outbound Call Center: Obtain missing documents and updating payer’s database.
- Follow-up with payers: Follow-up on submitted credentialing requests.
- Data Entry: Capture data, label and link images to specific providers/ facilities in payer’s database.
- Maintenance of Provider Data: Update provider information as per policies and procedures, and CAHQ profile.