Provider Credentialing and Enrollment

Provider Credentialing and Enrollment Services

Physicians/providers must credential themselves, i.e., enroll and attest with the Payer’s network and authorized to provide services to patients who are members of the Payer’s plans. The credentialing process validates that a physician meets standards for delivering clinical care, wherein the Payer verifies the physician’s education, license, experience, certifications, affiliations, malpractice, any adverse clinical occurrences, and training.

Payers may delay or refuse payments to physicians who are not credentialed and enrolled with them. These impact the financials of the practice negatively. Our customized Payer credentialing and enrollment services support physicians in:

Starting or joining a new practice
Switching from one physician practice group to another
Join or become affiliated to new groups or practices
Enroll with new payers

Maintain their credentialing services.

OUR CREDENTIALING PROCESS INVOLVES THE FOLLOWING:

Collect all the data and documents required for filing credentialing applications from the physicians
Store the documents centrally on our secure document management systems
Understand the top payers to which the practice sends claim and initiate contact with the payers
Apply the payer-specific formats after a due audit
Timely follow-up with the Payer to track application status
Obtain the enrollment number from the Payer and communicate the state of the application to the physician
Periodic updates of the document library for credentialing purposes

Our Provider Credentialing Services Include:

CAQH Attestation

Council for Affordable Quality Healthcare, Inc. eliminates redundant and inefficient administrative processes between health plans and providers for credentialing, directory maintenance, coordination of benefits, and other essential business functions.

CAQH application filing
CAQH quarterly attestations

Expirations and Renewals
- The tracking expiry date for State DEA License, Board certificate, and Malpractice Insurance

Tracking and Analytics
- Maintaining a repository of provider’s credentialing documents
- Maintaining Contracting agreements
- Tracking credentialing dates, expiration, and alerting dates to initiate credentialing processes
- Working with the denials team to understand if there are any claim denials due to credentialing issues

New Registrations/Renewals of an Individual Provider

With the State
With the Drug Enforcement Agency (DEA)

Provider Data Maintenance – Update Management on Payer Systems
- Provider demographic update in payers file. (Updates of Provider’s specialty or additional educational qualifications)
- Provider directory maintenance on payer websites. (Checking payer website and verifying provider details like Phone and Fax #, Zip code. Updating the correction to payers )
- EFT/ERA enrollments

Contracting Creation and Maintenance
- New Group/Individual Practitioner contracts
- Adding / Deleting providers in the existing contract
- Adding/Deleting location in the current contract
- Adding / Deleting plan types ( Line of Business ) in the current contract
- Rate Negotiation

Benefits of our Credentialing and Enrollment Services

With our diligent credentialing and Enrollment services, you get the following benefits:

Get credentialed faster with all significant payers
Reduce claim denials and improve cash flow
Get more patient referrals from the network
Avoid piles of paperwork with our document management system
Get support for filling up cumbersome application forms
Reduce costs of the credentialing process with our global delivery teams
Get timely reports on the status of your applications

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