Is there a difference between the provider credentialing and the enrollment?

Provider credentialing and enrolment are the two different legislative protocols that have been established by the Medicare and Medicaid Services (CMS). Medical providers are legally bound to follow these processes to provide their medicare services and participate in the medical practices to perform healthcare procedures. These two terminologies seem similar and two parts of the same puzzle that raise confusion in the mind of the intended personalities who need these; as per the survey conducted by the American medical association (AMA), almost 50% of the medical graduates and providers that are involved in the process of credentialing and the enrollment are confused between these two that resist them in interacting with the insurance carriers to get their job done. Additionally, a 2018 National Association of Insurance Commissioners (NAIC) survey found that nearly two-thirds of Americans reported not having a good understanding of provider enrollment and the credentialing processes. In this connection, this post aims to navigate you through the procedure’s details and demonstrate what you need to know about these two different systems.

Core variations between the provider and the credentialing enrollment

Neither of these two processes is different; neither they are the same. Instead, one is a component, requirement, and a part of the process of another. We will differentiate between these two in great detail in the next to no time. For the time being, provider enrollment is a requirement for all providers who want to be covered by the health insurance plan. While credentialing is a requirement for the completion of the provider enrollment process, where the verification is performed on the medical providers to know whether they meet the qualifications to perform medicare and the medical procedures or not.

Medical provider enrollment or payor enrollment

Being a medical practitioner, it is critical for you to understand the enrollment process and what are the prior requirements for it to be a part of the government health insurance programs. Before we get into the requirements, let us elaborate on the legislative resources, as per the American Medical Academy; this is a required process of applying for the health insurance plans/networks for inclusion into provider panels to bill and be paid for the rendered services. This process comprises two parts Credentialing & Contracting; here is the description.

Credentialing

Steps involved in a process

• The provider submits a participation request to the health plan using their application process.
• This process varies from completing a unique credentialing application, using CAQH, or accepting a state-standardized credentialing application.
• A detailed and thorough credentialing verification of the provider is performed upon receiving the enrollment application.
• When all the credentials verification, formally known as the Primary Source Verification, gets completed, Credentialing Committee goes through the credentialing file for approval, which takes up to 90 days.

Legislative requirements for the physician credentialing

As previously discussed, provider enrollment is a process of applying for health insurance plans/networks for inclusion into the provider panels. These providers’ panels may include Medicare, Medicaid, and Tricare; other health programs are connected to the government, but those are slightly different. These programs require completing and submitting a standard form to the designated intermediary responsible for managing the administrative tasks related to the program in your jurisdiction. Medicare reviews your application as per its strict enrollment standards; these legislative standards regarding their enrollment process are publicly available on the CMS website. Some of the critical items to remember when applying for Medicare are:

• The primary place of service in operation is a must.
• Banking information is required to set up the EFT payment for your Medicare reimbursement.
• You must provide personal details for all medical practitioners who are involved in your practice.
• Supporting documents are different as per the type of provider
• Documents for citizen verification are required; this requirement is for providers who were born outside the US.
• For the providers who completed their education outside the United States, ECFMG is required.
• Signatures are required on all your application forms correctly in every signature location.

Because the process is very detailed, you must acquire the assistance of someone experienced in Medicare enrollment to get your application reviewed before submission.

It doesn’t matter who is handling your provider enrollment applications; the primary thing to consider is you should not wait. The legislative standard process is lengthy, and until the process doesn’t get completed you will not be eligible to receive “In-Network” reimbursement until your agreement becomes valid. As per the Medicare legislative regulations, you are required to bill 30 days before they receive your application. Therefore, you can back bill to your effective date of Medicare takes 60 days to process your application, but commercial carriers do not permit that kind of back charging.

If you want further assistance in the matter of provider enrollment and credentialing, you can acquire the assistance of MedsIT Nexus medical billing services or can adopt a second option to call on a number +1 (516) 665-1869 to discuss our services and how we can assist your specialty. Additionally, you can fill out our quotation form for more information on our service plans and pricing.