Credentialing

Credentialing is the payer’s background check. Before a health plan lets a provider treat its members as a participating provider, it verifies the provider’s licenses, degrees, residency or training, board status, work history, malpractice coverage and claims history, and any sanctions. Most commercial plans pull that information from a CAQH ProView profile the provider keeps attested; Medicare and many Medicaid programs run their own enrollment process instead. Hospitals and surgery centers credential separately for privileges.

Credentialing matters to billing because it sets the effective date. A payer will not pay in-network claims for dates of service before the date it finished credentialing and loaded the provider into its system. Claims sent early deny as provider not eligible or not enrolled on the date of service, and whether a payer will back-date an effective date is up to the payer. Charges for those dates either wait, go out of network or get written off.

The mistake is confusing credentialing with enrollment and assuming one approval covers both. Credentialing verifies the person; enrollment and contracting attach that person to a tax ID, a location and a fee schedule. A provider can be credentialed and still have no way to be paid, because the group contract was never linked. Track each payer separately, record the submission date and reference number, and hold the provider’s claims for that payer until the effective date is in writing.