The Intake

Insights for those starting, managing, and growing independent healthcare practices

What to know about insurance credentialing when starting your own practice

There are many steps involved in getting your practice up and functioning. One of the items to check off your list as soon as possible is getting credentialed with various insurance companies.

Physician thinks about the process of how to become credentialed with insurance companies

At a Glance

  • Credentialing is necessary for providers to get reimbursed by insurance companies. It involves submitting personal, professional, and practice information to insurance companies and signing a contract outlining the services, fees, and reimbursement details.
  • Providers need to research which local insurances to credential with, gather all required documents, submit to insurance companies/CVOs, and follow up throughout.
  • Insurance credentialing must be renewed regularly, though the time frame varies by company.
  • Practices should use calendars, file organization, and backups to track credentialing timelines and documentation.

What is credentialing in healthcare, and how can it help your practice? This article will cover:

  • Why you need to be credentialed with insurance companies
  • What you need to do to obtain insurance company credentials for your medical practice
  • What barriers may be between you and your goal of being credentialed
  • Whether or not you need to renew your medical practice’s credentials with insurance companies
  • Who needs to be credentialed within your medical practice

Obtaining credentials from insurance companies will allow you to accept more and a wider variety of patients. You will be better able to help your community. You’ll also be better able to grow your revenue.

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Why should I get insurance credentials?

Being credentialed is not the same as being licensed. In the United States, a medical license indicates that you have:

  • Passed your state’s medical boards
  • The appropriate knowledge and education to practice medicine
  • The right to be known as a physician

However, being credentialed with various companies and agencies allows you to get reimbursed via claims you submit for a variety of procedures you offer. Insurance companies, including Medicare, require additional verification of your information, including information about malpractice claims, to officially deem you a safe and trusted provider for their members. 

What is involved in getting my medical practice credentialed with insurance companies?

Before we dig into the process, let’s discuss how you determine who within your practice needs to be credentialed.

  • The easy answer to that question is anyone within your practice who is a medical provider must be credentialed. This includes not only various physician specializations but also other roles, including nurse practitioners, physician assistants, respiratory therapists, and nuclear medicine technologists, among many other roles.

Credentialing requirements vary by state. Therefore, check your state’s medical board website to verify who on your staff must go through the credentialing process.

Check your state’s medical board website to verify who on your staff must go through the credentialing process. ”

At this point, apply for or update your national provider identifier (NPI), if you haven’t already. This is a unique 10-digit designation that each healthcare provider uses to identify themselves in their standard treatment documentation and transactions.

Research which insurances are typically used in your area

Not all insurance companies or plans are standard in every area. With that in mind, determine which insurance programs your patients will likely expect you to accept. In addition to major national carriers such as Aetna, Blue Cross/Blue Shield, Cigna, Humana, and United Healthcare, consider any common regional insurance carriers, along with Medicare and state-based programs like Medicaid. One way to go about this is market research — you can call or visit the websites of your competitors to see which insurances with whom they work.

Once you have compiled this list, call each insurance company to determine which panels are and aren’t open to new practitioners at the current time. For those currently closed to new applicants, find out when they anticipate accepting new credentialing applications.

The credentialing process takes time to complete, so ensure you have your basic facts together before you start the official process.

Now that you’ve identified which insurance boards to approach for credentialing and which currently accept new practitioners, complete a pre-application for each. This part of the process allows the insurance carriers to conduct a semblance of a background check to ensure that you have the basic qualifications to enable you to practice medicine.

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Gather your relevant information

Once you’ve submitted your pre-application to each company, it’s time to gather all of the pertinent information.

You will need to provide the following:

  • Basic personal identifying information: Name (including previous/other names), mailing address, email address, daytime phone number, citizenship information, a recent photograph, date of birth, Social Security number
  • Professional background information: Your current CV with qualifications to practice and your career history, education and training, residency, licensing, specialties, associated certificates, languages you speak, sanctions or disciplinary actions you’ve received, any malpractice claims history, board certification, continuing medical education certifications, peer references
  • Practice information: Practice address (physical and mailing), phone number, tax ID, primary contact, your NPI, names and NPIs of any medical group and hospital with which your practice will be affiliated, proof of professional liability insurance, verification you will accept new patients, the age of your target patient cohort

Group credentialing is available when you are joining or starting a larger practice. The initial application process is similar to what happens when an individual provider or a practice with just a few physicians apply for credentialing. However, the ongoing process focuses only on the individual new provider information because the physical practice information doesn’t change.

To help you organize your data, consult the following  checklist you can use to ensure you have gathered everything you need. ”

Send this information as one cohesive packet. If you send it piecemeal, portions will likely be misplaced or attached to the wrong file. To help you organize your data, consult the following  checklist you can use to ensure you have gathered everything you need.

Insurance company credentialing information packet

Insurance provider:
Contact name:
Contact phone number:
Personal informationProfessional backgroundPractice information
Legal nameCurrent CV with qualifications, career historyPhysical address
Alias(es) and/or previous name(s)Proof of education, training, residencyMailing address
Physical addressLicensingPhone number
Mailing addressSpecializations and associated certificatesTax ID number
Email addressLanguages spokenPractice primary contact
Daytime phone numberSanctions or disciplinary action documentationNPI
Citizenship informationMalpractice claim informationAffiliated practices and hospitals
Recent photographProof of board certificationProof of professional liability insurance
Date of birthContinuing medical education certificationsWilling to accept new patients
Social Security numberPeer referencesAge range of target patients

The insurer may use a third-party company called a credentials verification organization (CVO) to gather and parse through all of your documentation. Most will accept your information via email, electronic document transmission, or snail mail.

In some cases, the CVO may do a lot of the background searches to gather various pieces of your packet. For it to do this, you will likely need to sign an affidavit allowing it to access your personal information.

Regardless of whether you work with a CVO or a company representative, get a contact name, direct phone number, and email address when possible.

Contracting with the insurance company

Once the insurance company approves you for credentialing, you will enter the contract phase. During this process, you contract with the insurance company outlining which in-network services you will provide, the percentage of your fee they will reimburse, and how you will receive reimbursement from them.

The contract will also define which party is responsible for instances that involve multiple insurance companies. The coordination of benefit-filing responsibilities often initially falls on the practice, then shifts to the insurance companies as they determine which company pays what percentage of the treatment bill.

Are there any barriers to becoming credentialed with insurance companies?

There are 3 potential challenges that might arise during your credentialing process.

First, not all insurance providers within an area are open to additional medical professionals. In some instances, the insurance company’s market research may indicate the market is at a saturation point regarding its services. If this happens, ask the representative if they know when that decision may change.

Not all insurance providers within an area are open to additional medical professionals. ”

Additionally, share any information you have that the insurance company doesn’t, such as if you are taking over an existing practice and will acquire an established patient base that is accustomed to having their insurance accepted. This may influence a different decision.

Second, some companies require experience before contracting with a new physician. This doesn’t apply to all companies and is less frequent than it used to be. Still, some indicate they want a medical professional to have anywhere from 6 months to 2 years of experience before they will include that individual in the credential process.

Third, not planning enough time to complete the process. Multiple websites and agencies suggest you need to plan 6 to 10 hours to gather your information to simply begin the credentialing process. Once you submit your packet to each insurance company, you will have to schedule time to follow up with those organizations, gather additional information they request, and keep your application process moving forward.

Know that just because these are potential challenges, it is not a given that you’ll run into them.

How long does the credentialing process take from start to finish?

The length of the process varies depending on the company or agency with whom you’re working. In general, you can estimate the approval time:

  • NPI application: 30 minutes
  • Medicare and Medicaid: 40 to 60 days 
  • Commercial insurance carrier credentialing: 60 to 90 days, plus 30 days for contracting
  • State credentialing: 90 to 150 days
  • Online CAQH application: 3 hours

If you plan to practice before you receive your official credentials, you can request a statement of supervision. This will allow you to temporarily bill under a supervising physician until your credentialing process is complete.

Do I need to renew my practice’s insurance credentials?

You will need to renew the insurance credentials for your practice. The frequency depends on the company. Some require renewals every 12 months, others up to every 3 years.

The good news is that there are companies you can hire and software programs you can use to manage credential processes. This is a process that a competent office manager could track and care for. Once your practice is up and running, this is likely not an area on which to spend your time.

The good news is that there are companies you can hire and software programs you can use to manage credential processes. ”

You must know that any time your practice is affiliated with a different employer tax ID number (EIN), you will need to obtain new credentials. Your insurance credentials do not move with you from one medical practice to another.

Do the insurance credentials cover every physician in my practice?

This depends on your practice type and the credential application you completed. There are some instances where medical practitioners can complete a group application; however, not all practices are eligible for this umbrella.

When a new medical professional joins your practice:

  • Verify that all of the credentialing information the insurance companies have on file for your practice is current
  • Your credential coordinator must complete a Council for Affordable Quality Healthcare (CAQH) application
  • Authorize the relevant insurance companies to access the CAQH application
  • Empower your credential coordinator to frequently follow up on the new application’s status with the various insurance companies

You already know you need to renew your credentials with the multiple insurance companies and agencies you will work with and to whom you will submit payment claims. Still, you should also be aware that you will need to validate that your CAQH information is current.

How to manage the deadlines

Due to the plethora of moving pieces in this overall process, it is best to:

  • Put reminders in your office’s electronic calendar 3 months before your credential expiration date
  • Maintain files of all information gathered for each insurance company, including all current certification information and subsequent renewals
  • Ensure your electronic information is backed up so the critical information does not get lost and require recreation

Keeping this information organized while you are initially going through the process will save you an exponential amount of time later.

Wrapping up the credentialing process

Obtaining insurance company credentials for your practice may initially seem drawn out and daunting. The good news is that you can complete many other tasks to move toward your goal of getting your practice up and running while you wait for various stages of the process.

Once your insurance company credentials are in place, you can accept your patients’ various insurance plans. ”

Once your insurance company credentials are in place, you can accept your patients’ various insurance plans. Afterward, you can submit those claims to the associated insurance companies for reimbursement, or even better, outsource that function and have someone else manage the insurance billing process on your practice’s behalf.

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Written by

Karmin Gentili

Karmin Gentili has been a freelance writer and editor since 2016. She has over 25 years of experience in corporate HR and compliance consulting. She has worked to further elevate her skills by pursuing and receiving multiple certifications, including copywriting, video scriptwriting, effective content positioning, case study writing, and SEO. Her love of writing motivates her to use those skills to develop content for the medical field that ensures others can work toward achieving their goals.

Reviewed by

Lauren Wheeler, BCPA, MD

Dr. Lauren Wheeler, MD, BCPA, is a former family medicine physician who currently works as an independent healthcare advocate as well as a medical editor and writer. You can get in touch with her about anything writing or advocacy at her website

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