The credentialing process or provider enrollment consists of two phases called credentialing and contracting. Insurance companies verify your education, training, and professional history during credentialing to ensure you meet the necessary internal requirements for an in-network provider. Then, the insurance company issues a participating provider agreement outlining specific terms for participation and receiving claim reimbursement. A provider agreement is a requirement for in-network reimbursement. However, you may have the option to bill as an out-of-network provider until completing your credentialing. Unfortunately, the insurance company does not guarantee claim processing. Additionally, claim acceptance depends on patient out-of-network benefits. Below is a checklist of items to prepare before beginning the credentialing process.
Credentialing and Contracting Preparation Checklist
- Establish a business entity like an LLC, S-Corp, or PC and obtain a tax identification number.
- Sole proprietors should consider obtaining a federal tax ID to protect their social security number.
- Purchase a professional liability insurance policy.
- Obtain a personal and business NPI number.
- Acquire licensure in the dental practice’s state with prescriptive authority.
- Establish and maintain a CAQH profile.
- Research and identify insurance networks for your practice.
Insurance Companies with Whom You Should Credential
Determining the best insurance providers for dental practices may seem overwhelming. Therefore, contact a peer at another local practice or an insurance billing office manager to inquire which insurance companies provide an excellent patient base. Other major dental insurance carriers to consider are Medicare, Medicaid, Blue Cross Blue Shield, United Healthcare, Humana, Aetna, and Cigna. In addition, major national PPO plans sometimes rent their networks in targeted areas, such as Multiplan. The small business consultants recommend seeking credentialing with multiple insurance companies to obtain a wide range of insurance coverages.
Insurance Companies with Whom You Should Credential
Determining the best insurance providers for dental practices may seem overwhelming. Therefore, contact a peer at another local practice or an insurance billing office manager to inquire which insurance companies provide an excellent patient base. Other major dental insurance carriers to consider are Medicare, Medicaid, Blue Cross Blue Shield, United Healthcare, Humana, Aetna, and Cigna. In addition, major national PPO plans sometimes rent their networks in targeted areas, such as Multiplan. The small business consultants recommend seeking credentialing with multiple insurance companies to obtain a wide range of insurance coverages.
Credentialing with Insurance Networks
Credentialing can be time-consuming and may require hours of application preparation and process follow-up. Dental office coaches at EZZDS Consultants advise clients to outsource the credentialing process to maintain patient or practice focus since it requires a significant time investment. Once you decide on the insurance carriers with whom to participate, follow the below checklist to begin the credentialing process.
Insurance Network Credential Checklist
- Contact network providers to obtain a credentialing application and inquire about the process. Most insurance carriers have the application and additional information on their website.
- Take your time and carefully complete the application. Be sure to sign and date the application, include location details for additional practice locations, as well as copies of required documentation.
- Update your CAQH profile to include complete information about your practice location and necessary documentation, such as a business license, insurance coverage, board certifications, etc.
- Keep a copy of your application once submitted.
- Verify your application submission with the insurance company. Then, follow up periodically to inquire about the status until notified that credentialing is complete and a participating provider agreement is signed.
- Respond rapidly to requests for more information from the insurance company to continue processing.
- Document your submissions, follow-ups, and additional activity you feel necessary.
- Carefully review your participating provider contract details to understand the requirements of a network provider.
- Maintain records of credentialing applications, submissions, and contracts, especially a final copy of the provider contract.
Once Credentialed
After completing the credentialing process, you may begin billing for in-network services. Be sure to verify the patient’s benefits before the appointment and submit claims within 24 hours of treatment for timely payment. Once payment is received from the insurance company, promptly post the payment and bill another insurance provider or the patient for the remaining balances due.
