Provider Credentialing Service

Provider Credentialing Service

Credentialing is the process of verifying a provider’s qualifications to ensure that they can provide care to patients. Most health insurance companies require this process including CMS/Medicare, Medicaid, and Commercial plans, as well as hospitals and surgery centers.

The providers credentialing process is completed by verifying all of a provider’s documents to ensure that they are valid and current. These include their medical license, malpractice insurance, and DEA.

Additional information necessary to complete credentialing:

  • Medical School information
  • Internship/Residency/Fellowship’s Information
  • Board Certifications
  • Provider’s CV

SWAGPRO credentialing services, we can assist you with provider enrollment and becoming an in-network provider so that you can receive reimbursements from each carrier. While just a few years ago healthcare professionals considered medical credentialing service “optional” for building a practice, today it has become more necessary than ever for providers to be in-network with insurance companies. Learn how Swagpro Medical Billing Services can help you get the proper credentials to open a medical practice.

The credentialing team delivers a knowledgeable and comprehensive service to assist you in becoming an in-network provider with the insurance carriers that you want to participate with. We can give you recommendations by performing analysis for your specialty and service area if you need guidance.

The credentialing team delivers a knowledgeable and comprehensive service to assist you in becoming an in-network provider with the insurance carriers that you want to participate with. We can give you recommendations by performing analysis for your specialty and service area if you need guidance.

When you have gathered your documentation and are ready to get started, contact us. We work with practices both large and small, including solo practitioners as well as large 30+ provider practices as well as 1 and 2 provider practices for both Medicare, Medicaid, and Commercial Payers for a group and individual enrollment. Our team has extensive knowledge and expertise for multiple specialties and services, including DME.

  • The medical provider credentialing process requires involvement from the healthcare provider, the organization, and the payer.
  • The organization typically provides the healthcare professional with the credentialing application(s). He or she is responsible for completing the application – which may be many, many pages long – and attaching all requested documentation like board certification, college degrees, and more. When the application is complete, the provider submits it to the organization he or she plans to provide services under.
  • The organization is then responsible for attaching additional documentation: any claims history, background screen results, primary source verification, and more.
  • Once they’ve completed any healthcare facility portions of the application and attached appropriate documentation, they submit the completed application and supporting documentation to the payer.
  • The payer reviews the application to determine whether the healthcare provider meets the payer’s standards. Things they’ll take into consideration include the provider’s education (and accreditation of that program), residency or fellowship, recommendations, malpractice claims history, license, and more.
  • This entire process is required when the provider first joins a new practice and then periodically thereafter – usually every two to three years depending on the payer.

What Information is Required for Credentialing?

Information is dependent on payers but tends to be relatively consistent across the board and typically includes:

  • malpractice claims history (suspensions, revocations)
  • license to practice and primary source verification
  • NPI number
  • license history
  • DEA license
  • work history
  • degrees and transcripts
  • references from previous employers/practitioners
  • insurance information
  • board certification

Most Asked Medical Credentialing Questions, Answered

1. What should you expect from your Medical Credentialing Service Provider Company?

The process should begin with reviewing your specific network needs or an evaluation of the top payers in your area. Once final decisions are made, a contract is executed for the work to be done and payment is made. The Credentialing team gathers all necessary documents from the provider and contacts the insurance companies to begin the application process. For most companies, the process can be completed online through their portal for form completion. If not, they will be filled out and then sent via the required method. After submitting the applications, timely follow-up with the payers is crucial to ensure they were received. We give bi-weekly status updates to the client to keep them informed throughout the process until an effective date of enrollment is determined and a contract is received and executed, so the provider can begin claim submission.

2. When you outsource your Credentialing, what does that medical credentialing company provide you?

Outsourced Credentialing companies should respond to requests in a timely manner and provide excellent communication and complete transparency. A provider should work with a company that is professional and caring, taking ownership in the process as your representative in dealing with the insurance companies.

3. How does Swagpro Medical Billing Services provide a complete physician credentialing service?

We assign them a Credentialing representative that they can communicate easily with and rely on. We offer to analyze their payers for their specialty and geographical location, as well as evaluate their contracts. We want providers to feel as though we are sitting in their office and are available when they need us.

4. How long does the provider credentialing process take?

The physician credentialing process generally takes between 90-120 days. We send a checklist of all documents that are required so that we can begin. Once they are received, we upload your data into our system and work to get your applications completed and submitted to insurance companies. We then follow up regularly with insurance companies to make sure that your credentialing applications are received and being processed and approved without unnecessary delays.

5. Do you have experience credentialing my specialty or for providers in my area?

Yes, we have credentialed for providers across the United States, including Hawaii, and for a variety of specialties and practice sizes!

6. Do you offer any service to keep up the documents and insurance contracts that expire and must be renewed?

Our Re-Credentialing and Maintenance package tracks expiration dates and renewals of contracts for your networks, such as BCBS, Aetna, and Cigna, as well as the various plans you are enrolled with under their umbrella, including Medicare and Medicaid re-validations. We also provide CAQH maintenance and attestation every 3 months, notifying the provider of expiring documents such as Malpractice, License, DEA, etc.

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