Setting up and operating your practice involves several processes. Obtaining credentials with various insurance firms should be one of the things you cross off the list as quickly as you can.

What is healthcare credentialing, and how can it help your business?

It covers:

  • Why it’s essential to have insurance company credentials?
  • What must be done to receive credentials from insurance companies for your medical business?
  • What obstacles might stand in the way of obtaining credentials?
  • Whether you require new insurance company credentials for your healthcare business
  • Who requires credentials for a medical practice?

Acquiring credentials from insurance companies enables healthcare providers to expand their patient base by accepting a greater diversity of patients. By enhancing your abilities, you will be able to assist your community. You’ll also be able to boost revenue.

What makes insurance certifications important?

Credentials are different from licenses in this regard. An American medical license certifies the following:

  • Passed the state’s medical licensing exams
  • The necessary education and training to practice medicine
  • The right to be recognized as a doctor

However, having accreditation with numerous organizations and corporations enables you to be paid via claims you submit for a range of services you provide. Insurance companies, including Medicare, must verify your data, including malpractice claims to declare you a reliable and reputable provider for their members.

What steps are involved in obtaining insurance companies’ credentials for my medical practice?

Let’s talk about how you choose which members of your practice need credentials before we get into the entire procedure.

The short answer is yes; all medical providers in your practice must have appropriate credentials. Along with different medical specialties, this includes other occupations, including nurse practitioners, physician assistants, respiratory therapists, nuclear medicine technologists, and many others.

States have different standards for credentials. Consult your state’s medical board website to determine if your personnel need credentialing.

Get your NPI immediately if you haven’t already. Each healthcare practitioner identifies themselves with this special 10-digit designation in their routine treatment documentation and transactions.

Find out what types of insurance are most commonly used in your region

Only some regions have access to the same insurance providers or programs. Identify which insurance plans your patients expect you to comply with. You should also consider Medicare, state-driven programs like Medicaid, and extensive national insurance providers like Aetna, Blue Cross/Blue Shield, Cigna, Humana, and United Healthcare.

Call each insurance provider after you’ve gathered this list to find out which panels are and aren’t currently accepting new practitioners. Find out if they plan to take new credentialing applications for those that are now closed to new candidates. Before you begin the official credentialing process, ensure you have your fundamental information organized because it takes time to complete.

Fill out a pre-application for each insurance board you plan to contact for credentialing after determining which currently accepts new practitioners. This procedure step enables the insurance companies to perform a rough background check to ensure you possess the minimal requirements needed to practice medicine.

Collect your essential information

It’s time to compile all the necessary information after submitting your pre-application to each company.

You must provide the following:

  • Identifying details for a person: Name (including former or alternate names), mailing address, email address, daytime phone number, citizenship details, a recent photo, date of birth, and social security number
  • Professional history: Your most recent CV detailing your credentials for practice, professional experience, educational background, residency, license, specializations, related certificates, languages spoken, sanctions or disciplinary actions you’ve faced, history of any malpractice claims, board certification, credentials for continuing medical education, and peer references.
  • Information on the practice: Primary contact information, your NPI, the names and NPIs of any linked medical groups and hospitals, as well as the practice’s address (both physical and mailing), telephone number, tax identification number, and the age of your intended patient cohort, confirmation that you are accepting new patients, and evidence of professional liability insurance

Group credentialing is an option for beginning or joining a larger practice. The first application procedure is comparable to that experienced by a single provider or a small group of physician practices seeking accreditation. Although the physical practice information remains constant, the continuous procedure concentrates primarily on the information about each specific new provider.

Negotiating a contract with the insurance provider

You’ll start the contract phase when the insurance provider gives you the go-ahead for credentialing. You agree with the insurance provider at this time, defining the in-network services you will offer, the portion of your charge they will cover, and the method you will pay.

The contract will also specify who is accountable in cases involving numerous insurance firms. Often, the practice is first responsible for coordinating benefit-filing duties, which eventually pass to the insurance companies as they decide which company will cover what proportion of the treatment costs.

Do insurance companies have any requirements for obtaining credentials?

Three possible difficulties occur during your credentialing process.

First of all, not all insurance companies in a given region welcome the addition of more medical specialists. Occasionally, market research conducted by the insurance firm may show that the demand for its services has reached a saturation point. Ask the person in charge if they are aware of any potential changes to the decision if this occurs.

Share any information the insurance provider needs to include, such as that you are taking over an existing practice. You will get a clientele accustomed to having their insurance acknowledged. This might affect a different choice.

Second, some businesses want experience before hiring a new physician. This frequency has decreased over time and does not apply to all businesses. However, others claim that before including a medical practitioner in the credentialing process, they require them to have somewhere between 6 months and 2 years of experience.

Lastly, more time is needed to finish the process. Numerous websites and organizations advise you to schedule 6 to 10 hours to compile your information and start credentialing. You must set aside time to contact the insurance companies to which you’ve submitted your packet to follow up, collect any extra information they may require, and keep the application process rolling.

Be aware that just because there are possible obstacles doesn’t mean you will necessarily face them.

How much time does it take to finish credentialing?

The length of the process depends on the organization or agency you’re dealing with. The approval time can be roughly estimated as follows:

  • 30 minutes for the NPI application
  • 40–60 days for Medicare and Medicaid
  • Obtaining credentials from commercial insurance carriers takes 60 to 90 days, plus 30 days for contracting.
  • Obtaining a state license takes 90 to 150 days.
  • Application for the CAQH online takes three hours.
  • A declaration of supervision can be requested if you intend to practice before receiving your official credentials.

By doing this, you’ll be able to temporarily bill for services under a supervising doctor while your credentialing procedure is finished.

Should I update the insurance credentials for my practice?

It is necessary for you to update your practice’s insurance credentials. The corporation determines the frequency. Others may only need to be renewed every three years, while some demand them every year.

The good news is that you can manage credential processes by hiring businesses or using software. An office manager with the necessary skills could monitor and oversee this procedure. You should not focus on this issue once your practice is up and running.

You must know that you will require new credentials whenever your practice is connected to a change in employer tax ID number (EIN). Your insurance credentials do not follow you when you switch medical procedures.

Are all of the doctors in my practice covered by insurance?

This depends on the kind of practice you engage in and the credential application you submit. Some situations allow medical professionals to submit a group application; however, not all practices are accepted under this umbrella.

When a new physician enters your practice:

  • Make sure the insurance providers have the most recent credentials for your practice on file.
  • To apply to the Council for Affordable Quality Healthcare (CAQH), your credential coordinator must fill out the form.
  • Enable access to the CAQH application for the necessary insurance companies.
  • Give your credential coordinator the authority to regularly check in with the various insurance providers on the status of the new application.

You are aware that you must update your credentials with the various insurance companies and agencies you will deal with and to whom you will submit payment claims to. You must, however, be aware that you must confirm the accuracy of your CAQH data.

When and how to set deadlines?

Due to the large number of moving parts in this procedure, it is necessary to:

  • 3 months before the expiration of your credentials, add reminders on your office’s electronic calendar.
  • Keep records of all data acquired for each insurance provider, including details of all current certifications and subsequent renewals.
  • Make sure to back up your electronic data so that it doesn’t disappear and cause you to recreate it.
  • It will take you far less time later on if you keep this information structured while you are first going through the process.

Finalizing the credentialing procedure

It may appear complicated and time-consuming at first to obtain insurance company credentials for your profession. You may accomplish a lot of other work while you wait for different phases of the procedure to finish to go toward your goal of starting your practice.

You can accept the numerous insurance plans offered by your patients once you have your insurance company credentials in order. Then, you can submit those claims for payment to the relevant insurance carriers or outsource that job and have someone else handle insurance billing on your practice’s behalf.


If you’re starting a practice, it’s crucial to understand insurance credentialing. You may provide a solid basis for your practice’s success by following the proper procedures, acquiring the relevant paperwork, and keeping up with insurance networks. Prioritizing appropriate credentials supports efficient operations and adequate reimbursement.

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