Q: What is Provider Credentialing?
A: Provider Credentialing is technically primary source verification (PSV) of all required elements for a provider to practice. However, it also commonly refers to the process of becoming linked with insurance companies in order to accept 3rd party (payor) reimbursement. In order to bill and receive payment, you must be credentialed or ‘enrolled’ with every insurance company you want to bill.
Provider credentialing can often be a very long, detailed and tedious process. Every insurance company has a unique and complex credentialing process that can take months to master. We provide these services to allow you to do what you love – spend meaningful time with patients!
Q: How long does the credentialing process take?
A: The credentialing process generally takes between 90-120 days. We complete and submit your applications promptly to insurance companies. We then follow up regularly with the companies to make sure that your credentialing applications are processed and approved as soon as possible.
Q: What is needed for healthcare credentialing and enrollment?
A: Although documents may vary by provider type and health plan, you will need to provide us with at least the following:
CAQH Proview profile and access
NPPES/ PECOS (Medicare system) access
Provider License
Certificate(s) of Insurance – Malpractice Insurance
Drug Enforcement Agency (DEA) certificate
Controlled Dangerous Substance (CDS) certificate
Board Certification(s)
Undergraduate & Post-Graduate Diploma(s)
Educational Commission for Foreign Medical Graduates (ECFMG) if applicable
Current Curriculum Vitae (CV)
W-9 IRS Form
Driver’s license
Collaborating or Supervising Physician Agreement for advanced practice nurses and independent pharmacists
Provider identifier numbers (most can be found in the above documents):
Individual NPI number (from the CMS NPPES Identity & Access Management System at https://nppes.cms.hhs.gov/#/ )
Group (Type 2) NPI number
CAQH Proview profile number (from https://proview.caqh.org/)
Credential (e.g. MD, DO, CNP, LISW-S) license number
DEA number
Board certification number and organization *especially important for nurse practitioners who want to bill Medicare*
Individual (state) Medicaid number; Group practice Medicaid number
Individual (federal) Medicare number; Group (PTAN) Medicare number
A: We specialize in credentialing behavioral health providers. These include psychiatrists, psychologists, psychiatric/mental health nurse practitioners, clinical social workers, professional counselors, marriage & family therapists, chemical dependency professionals (e.g. CDCA, LICDC), RNs, LPNs, and paraprofessionals recognized by Ohio Medicaid (Qualified Behavioral Health Specialists, Peer Recovery Specialists).
We work with both private practices (identified as Type 21 by Ohio Medicaid) and OMHAS-certified & nationally accredited agencies:
- Type 84 Community Mental Health Centers that provide assessment, therapy, CPST and/or mental health day treatment
- Type 95 Substance Use Disorder treatment (out-patient and residential) facilities that provide assessment, MAT (medication assisted treatment), SUD counseling and case management, IOP (intensive outpatient), PHP (partial hospitalization) and/or withdrawal management.
Q: Do you have experience credentialing providers in my specialty?
A: We credential with all health insurance plans in Ohio, including:
Medicare (through the electronic PECOS system which saves time and money, tracks all progress, and speeds up the process),
Medicare Advantage plans
Healthcare.gov Marketplace plans
Ohio Medicaid and Managed Plans (e.g. Aetna OhioRise, AmeriHealth Caritas, Buckeye, CareSource, Molina, UHC Community Plan)
MyCare Ohio Duals Medicare/Medicaid plans (e.g. Aetna Better Health, Molina)
Commercial (e.g. Aetna, Anthem BCBS, Cigna/Evernorth Behavioral Health, Humana, Medical Mutual, UHC/UBH)
Military (e.g. TriCare) and
Certain Self-funded and Private insurance payors.
Q: With which insurance companies do you credential?
A: We have helped dozens of mental health practices and behavioral health agencies with practice management and growth, including setting up the organizational structure, contractual and regulatory requirements, human resources (e.g. staff supervision requirements, job descriptions, practice management), recommendations for billers, guidance for executives, leaders and board members, revenue cycle management, and other vital aspects of a successful healthcare business.