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Credentialing Blog Series Part 1 of 4: What you will need to successfully credential!


Main Points

  • Terms

  • The complete list of information you will need to credential with insurance companies

Navigating credentialing is a lot like wading through concrete. It can be a long and slow process, but there are actions you can take in order to be as prepared as possible. In this credentialing mini-series, we will go through the credentialing process and the information that you will need in order to be successful at credentialing.

First, you will need to know some key terms and concepts! Below is a list of terms with their definitions and places for additional information.

Type 1 NPI - This National Provider Identifier that identifies a specific individual provider. This number is similar to a social security number in that it is specific to that provider and no one else and no other organization.

Type 2 NPI - This National Provider Identifier identifies a group or organization. However, the owner of the practice or organization will be listed as the point of contact for this NPI.

Tax ID - The tax identification number is the number that the IRS uses to identify your organization for tax purposes.

CP-575 - The form that the IRS sent you when you filed for your Tax ID.

CAQH - The Council for Affordable Quality Healthcare is an online database that stores provider information. Providers grant their information to insurance companies for the purpose of credentialing.

PECOS - The provider Enrollment, Chain, and Ownership System is an online Medicare enrollment system. This is where providers submit enrollment application. PLI - Professional Liability Insurance is the insurance that will cover your practice in the event of a malpractice lawsuit.

W9 - The form that has the full legal name of the business, filing status, and EIN/Tax ID

Here is the comprehensive list of everything you will need to credential with insurance companies successfully!

  • Address, phone numbers, and fax numbers of locations

  • Type 1 NPI for each provider

  • Type 2 NPI if applicable

  • Address, phone numbers, and fax numbers of locations

  • Tax ID

  • Copy of EIN letter from IRS (esp for Medicare)

  • Full legal name of business and filing status (LLC filing as S-corp, etc)

  • Provider specialties, populations (ages, areas of concern, etc) and evidence-based approaches to indicate in any provider databases

  • Provider’s standard work hours at each location (if not already in CAQH)

  • Provider’s CV (curriculum vitae) or resume including month and year as well as address for all employment or college & graduate schools

  • Other names if applicable (unmarried name etc) and dates

  • Provider date of birth and SSN

  • Liability insurance

  • State license

  • Department clinician was in for internships

  • Any other certifications (CADC etc) being uploaded to CAQH

  • American Disabilities Act Compliance information for office (wheelchair accessible, bathrooms ADA compliant)

  • Proximity to transit

Stay tuned for Part 2 of the blog series: The Pitfalls of Credentialing!

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