How to Know If You Are Credentialed With an Insurance Company
Unless you have completed the credentialing process for an insurance company, you are likely not credentialed with them. In this article, we are going to talk about ways that you can verify which insurance companies that you are credentialed with, how to maintain your credentialed status, and what to do if you find out that you are not credentialed with an insurance company.
Question 1: Have you completed a credentialing application and received a contract within the last three years?
If you have not completed the application process, or worked with a credentialing company to complete the application process, then you are most likely not credentialed with the insurance company. Proceed to Question 2.
If you have completed this process and received a contract within the last three years, you are most likely credentialed with that insurance company. If you have a contract, it should have an effective date on it at which point your contract was deemed active. Insurance companies typically require that you renew your credentialing every three years, so if the date is more than three years ago and you have not renewed you should reach out to the insurance company and check on your credentialing status. Be prepared with your NPI number, tax ID, and additional identifiers so that the insurance representative can check on this for you. If the effective date listed is less than three years ago, you are likely credentialed with that insurance company! If you are experiencing issues with claims processing as an out of network provider, there are a few things that you should check:
The NPI and Tax ID submitted on the claims match the NPI and Tax ID that was submitted when you credentialed
Whether the patient’s insurance plan has a carve out for mental health benefits
Check with the insurance company to make sure that you are listed as a credentialed provider, and verify the information that they have on file for you
If you check with the insurance company and they tell you that you are not a credentialed provider but you would like to be, you will need to complete the credentialing process.
If you have previously submitted an application, you can ask the insurance representative for the status of your application. Credentialing can take several months, so it is possible that your application is still processing. If you’ve hired a company to do the credentialing for you, check with that company to find out the status of your application.
Question 2: Have you worked for an employer submitting claims to the insurance company in question?
If you have not been a part of a group practice where you or others were submitting insurance claims, then you are likely not credentialed with an insurance company.
If you were working under an employer and submitting claims to an insurance company, but have since branched out to start your own practice, you may or may not still be credentialed with that insurance company. There are two different ways that you could have been credentialed if you were working as part of a group. The first way you may be credentialed is under a group NPI in which case you would need to submit a new credentialing application as an individual or for your new business. The second way you may have been credentialed is as an individual using your Type 1 NPI, in which case you may still be able to submit claims in your new practice. You will need to verify with your previous employer as to how you were credentialed. If speaking with your previous employer is not an option, you can call the insurance company to verify this information. If they tell you that you were credentialed as part of the group, you can then ask how to move forward with credentialing as an individual. If they tell you that you were credentialed as an individual, at minimum you should verify the NPI, tax ID, and address and if there are any updates that need to be made you can ask the representative what steps need to be taken.
For more information about the two different models of credentialing a group practice, read this blog post.
Calling the Insurance Companies
If there is any question about whether or not you are credentialed, it is best to call the insurance company directly to verify. First, identify the list of insurance companies that you think you may be credentialed with based on applications that you know have been submitted, or insurance companies that you have worked with previously.
Once you have created your list, you need to make sure that you have all of your important identifiers handy. If there are multiple possibilities for NPI or tax ID, you should have all of them ready for the insurance company to be able to check. It may be helpful to create a cheat sheet for yourself with your NPI, tax ID, possible addresses, names, etc to reference while you are on the phone with each insurance company.
Call each of the insurance companies on your list to verify whether or not you are credentialed. Once you have a clear understanding of which insurance companies you are credentialed with, you can make further decisions for your practice such as whether or not to credential with a company that you are not credentialed with, or whether you should exit any insurance panels.
Maintaining Your List
Once you go through and verify which insurance companies you are and are not credentialed with, you can easily maintain this list going forward by doing the following:
Store your insurance contracts in an easily accessible yet secure location. The contracts are the concrete evidence of being credentialed with an insurance company.
Make sure that you maintain your status by re-credentialing when the insurance company indicates that it is time to do so. If you no longer wish to be credentialed with that company, you can let your contract lapse, and you can update your records that you are now an out of network provider.
If you credential with new insurance companies, be sure to add them to your EHR and indicate that you are an in-network provider.
Now that you've got your list of payers all straightened out (or maybe you still need a little guidance) it would be a great time to consider hiring a biller to help you manage claim submissions, follow ups, and payment posting. If this sounds like something you would be interested in, reach out to us today via our contact page to learn more!