Frequently Asked Questions

Both credentialing and provider enrollment are essential for healthcare providers, credentialing verifies a provider's qualifications and background while provider enrollment establishes eligibility to bill and receive reimbursement from a specific payor.

CREDENTIALING: 

• FOCUS: Verify a healthcare providers qualifications, training, experience and licensure to ensure they are competent to provide care
• PURPOSE: to ensure patients receive care from qualified and authorized healthcare professionals
• PROCESS: Involves gathering and assessing documentation of a providers education, training and work history, and malpractice claims history.

PROVIDER ENROLLMENT: 

• FOCUS: Establishing a contractual relationship with insurance payers, allowing providers to bill and receive reimbursement for services rendered.
• PURPOSE: To ensure that providers are eligible to bill and be reimbursed by specific payers.
• PROCESS: Involves applying to be included in a health insurance network, completing necessary forms and signing contracts. 

WHAT WE DO:

At Credibility, we excel in supporting you in the construction, maintenance, or enhancement of your Credentialing processes. Our expertise extends to hospital and surgery center credentialing and re-credentialing. Feel free to let us know how we can assist you in navigating the intricate landscape of healthcare credentialing with precision and effectiveness!

 A standard timeline typically spans 90-120 business days upon receipt of the provider’s application by the insurance company.  At times it can be quicker to process sooner then that and then there are times it can exceed the 120-day mark but each situation is different.  Every provider and every payor and requirement is different and state.

 Until a contract with a payer is fully executed with a payor, it is recommended that a health care provider refrain from initiating billing .

If it is necessary to provide services to an out of network member its suggested that you communicate the payor whether you should hold your claims until AFTER the contract is fully executed or if you should go ahead and submit them 

If a provider delivers services to a patient before obtaining the effective date and the fully executed counter-signed contract, reimbursement may still be possible as an out-of-network provider, provided the patient's coverage permits such arrangements. However, it is imperative for the patient to be informed and conscious that they will be utilizing their out-of-network benefits in such instances.