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April 6, 2023

Credentialing in medical RCM: Importance, Types, Steps Involved, & Benefits

Febien Caltin is a dynamic professional with 20+ years of extensive experience in the healthcare RCM space. He has expertise in Consulting, and Strategic Planning on solving critical issues healthcare providers face in the RCM process. Febien is committed to the growth of healthcare providers through his immense experience.

ABA Providers Recover Dues From Patients To Efficient Your Account Receivables

Everyone needs to get credentialed, whether you are an individual healthcare service provider or a group. The credentialing process validates that an individual or group meets the standard for offering healthcare services to patients. As patients have various options to get healthcare services, providers must get credentialed with most of the relevant payers in the industry.

To attract more and more patients, providers must gain the trust of leading healthcare insurance companies. How do you gain the trust of payers? You need to meet their credentialing requirements. In this blog, we have deep-dived into all aspects of credentialing, like importance, steps involved, benefits, and more.

In this blog:

What is Credentialing?

Credentialing is a part of the revenue cycle management process that verifies if a facility, healthcare provider, or organization meets the criteria to provide healthcare services to patients. Credentialing is an important process in revenue cycle management healthcare. Payers rely on provider credentialing to decide how much they reimburse the covered patients. The per month loss to an individual healthcare provider due to delay in credentialing can amount to more than $30k.

Credentialing involves extensive resources, information, and paperwork from healthcare providers, depending on the type of credentialing. Different payers and states have their own set of required documents and guidelines. Thus, the time required to complete the credentialing process varies from days to months.

The application process for credentialing is long, and the different forms should get submitted to different organizations. Applicants must know where to submit which form to ensure quick approval.

Submitting the credentialing application is not enough. You should follow up with CVOs (Credentialing Verification Organizations) to keep the process running smoothly.

What are the types of Credentialing?

Credentialing is the most complex process required to grow your practice. Majorly there are two credentialing options available, individual and group. Both processes require an almost similar process. You also get an option to get credentialed individually and connect with a practice’s tax ID number.  

To get credentialed, you have to apply with a resume, work history, areas of expertise, etc. Then the application is submitted to the payers. The process takes around 2-6 months if the application and supporting documentation are correct.

Individual credentialing

A healthcare provider who has individually credentialed has more flexibility and freedom than a group person. Individual healthcare providers who get credentialed with most payers can easily move between the practices. Credentialed individuals get their tax ID number and can bill separately from the practice. If you get credentialed, you can submit claims and get reimbursement no matter what practice you belong to.

Individuals get credentialed if they meet all the necessary criteria of the insurance company. Payers have set very specific criteria on what services are covered and what will not. Payers provide credentialing to a specialty, and all the services offered outside the specialty will not get reimbursed.

Group credentialing

In group credentialing, each healthcare provider must submit their documents and certificates under one big application. All the individual providers must meet the requirements of the payers. Only then the application for credentialing is processed.

Group credentialing requires the same set of documents that an individual requires. The biggest advantage of a group is credentialing does not go if an individual practitioner decides to leave.

Steps involved in the credentialing process

Steps involved in the credentialing process

When you are an individual healthcare service provider, nurse practitioner, or group, you must follow all the steps in the credentialing process.

“Credentialing is an expensive and time-consuming process. It occupies most of the facility’s resources. Healthcare providers must follow all the steps involved in credentialing to avoid complications,” says Lakshmi Narayana, Assistant Vice President of Plutus Health.

Look for the required documents  

Each healthcare insurance payer has its own set of document requirements. You should know each payer’s guidelines, documents, and forms to get quick approval. Even the slightest error in the documents or missing information can delay approval from days to months.

To get thorough with all the required documents, you can list all the insurance companies you want to get credentialed with. Then look for all the required documents. Here are a few documents you should keep handy while submitting the claims.    

  • Name
  • SSN (Social Security Number)
  • Demographic information
  • Education information
  • Residency information
  • Career history
  • Proof of insurance
  • Claim history
  • Proof of licensure
  • Data about your healthcare facility
  • Specialty and patient focus

You mention most of the information in your resume, but you should also ensure its accuracy and submit all the accurate, relevant documents.

Prioritize the payers

You must get credentialed with maximum payers and submit multiple applications to increase your patient base. But it is vital to prioritize your payers you want to submit documents first. You should stay updated with the payer regulations as it helps to get credentialed faster.

Find the accurate information

After you collect all the relevant documents and begin to submit a credentialing application, ensure that the accuracy and quality of the application get mentioned. You can conduct a background check to ensure accuracy.

Verify licensing, history, board certification, reputation, clinical privileges, and peer references through ECFMG (Educational Commission for Foreign Medical Graduates Certification), AMA (American Medical Association), and ABMS (American Board of Medical Specialties). Review privileges, history of credentialing, and insurance claims. You can list any restrictions with the OIG (Office of Inspector General). Errors in submitting any of these errors can cause issues in credentialing.

Finish the CAQH

Many payers demand the applicant to apply for credentialing from CAQH (Council for Affordable Quality Healthcare) along with the individual application. Once you have applied with the payer, they will invite you to apply with a CAQH number. You can choose to complete CAQH online or offline. Any insufficient or incorrect information can lead to a significant delay in approval.

Initiate Application/LOI to the payers

Once the CAQH process gets completed, initiate the credentialing application with the payers. You must complete the application form and submit all the documents to the payers. When you fill out the application form, ensure you don’t commit a mistake. Even a small piece of missing information or error can cost you a hefty loss in effort and time.

Follow-up with the payers

“Building relationship with the key personnel of the payers is important. You should build rapport with executive assistance and leadership to ensure that the application is processed on time. ”

Just submitting the credentialing application form to the payers is not enough. It is vital to follow up with the payers on the status of applications. Sometimes, your application can get delayed, and you must stay in touch with the payers. There is a heavy flow of credentialing applications towards the payers, and they individually can not respond timely on acceptance or rejection of the providers. You should take follow-ups until you get a final acceptance or rejection from the payer.

Wait for the revert from payers

Credentialing is a long process. You can not just apply and keep following up with the payers. The credentialing process can take from 45-90 days if your application is perfect. But there are cases where the application took more than 180 days.

Acceptance and process of applications depend on the volume of applications, and payers process them according to their own rules. You have to wait for the revert for the time given by payers and follow up only when the wait time gets completed.      

Contract negotiation and documentation

Contract negotiation is the most crucial step in credentialing, as a major part of your income will come from the payers. There might be conditions that the payer put in while approving the credentialing process. It is optional to accept all the terms of the payers. You should negotiate your terms with the payers and come to a conclusion that is beneficial for you and the payers. If you do not negotiate, it will affect your revenue and cash flow.


Once you complete all the steps, you will get credentialed with the payers. But this does not imply you will forever stay credentialed with the payers. Credentialing is a continuous process, and it demands regular work and updates. If you find any error in the employee’s information, updating this to the payer is vital. Mostly you need to be credentialed every three years.

You can use credentialing software to complete the process. This software even reminds you when to get re-credentialed. Even the payer sends the re-credentialing notification. You should contact the insurance company officers and promptly respond to them. Building connection helps to make the complete process simple and fast.

What are the mistakes to avoid while doing credentialing process?

Credentialing is a complex and time-consuming task. Even the slightest mistake in this process causes a hefty financial loss to healthcare providers.

“Mistakes while credentialing might affect the bottom line of your practice. You can even face legal compliance issues with improper credentialing.”

Here are the common credentialing mistakes you should avoid.

Data entry mistakes

Denials or delay in credentialing happen due to data entry mistakes. There can be common errors like:

Typo errors Mistakes when entering the data, such as interchange or wrong information, happen. It is important to check for wrong NPI numbers, improper license numbers, improper addresses, misspelled titles, and more.

Missing InformationNot entering the required data or completely removing an important document due to confusion comes under common data entry mistakes in credentialing.

Improper documentationPoor organizing and handling of documents lead to confusion in the complete credentialing process and often might lead to denials.

Timing and planning mistakesCredentialing demands the verification of various documents and information. It takes, on average, 3-4 months to complete the process. Preparation and collection of the required documents might also take longer than expected. Your staff should plan for this delay to avoid future complications. Unless you get credentialed with the payer, you won’t be able to receive reimbursement for the services offered. Improper timing and planning lead to more disaster for you and your practice.

Application process mistakeFiling and submitting proper applications is the first and primary step in the credentialing process. There might be many mistakes that can happen while you submit a credentialing application. Here are the things that can go wrong here.

Incomplete applicationIf any section of the credentialing application is kept blank, it is considered incomplete. Payers reject this kind of application. You should have all your documents, as missing the credentialing process might lead to obscurity in your career.

Improper authorizationThe credentialing application sometimes lacks verifications from the individuals involved. Improper authorization is considered a grave mistake in the credentialing process leading to rejection.

DelaysIf you delay the queries of the payers regarding the application, your application can be stuck in between. Ensure that your staff doesn’t miss any message from the payer regarding the credentialing application due to their busy schedule.

Unable to track application status

There are scenarios where the credentialing application gets stuck if there is a heavy flow of applications toward insurance companies. You should follow up with the insurance companies and track the application status. Tracking the application will reduce delays, and you can take faster action in case of denials.

Compliance mistakes

Credentialing requirements vary from state to state. Failure to meet these requirements could lead to denials and revenue loss. Compliance mistakes in credentialing might happen due to:

Staff ignorance Check if your staff shows casual or ignorant behavior when allotted credentialing procedure. Ignorance by staff can mess up the complete process. You need a trained staff to tackle such issues.

No knowledge of the standard regulationEach payer has a different enrollment process and credentialing criteria. If you are not compliant with the criteria will lead to payment delay.

Lack of awarenessYour clinical staff should be aware of the legal implications of the application. A lack of knowledge of legal jargon can lead to legal risks.

Enrolling process mistakes

Billing and payment are directly related to the enrollment process. Hence, errors in enrollment might affect your revenue cycle. Let’s look at some of the enrollment mistakes:

  • Payers have their timelines, regulations, rules, and protocols. Not meeting the enrollment criteria might lead to issues in credentialing.
  • You should know the payers around your locality. Not having sufficient knowledge about the payers in your area is one of the biggest enrollment process mistakes.
  • Payers might connect with you in case of quarries before enrolling. You should allocate your staff to connect with the payer and clarify these quarries. Failing to do so might lead to the denial of credentialing requests.
  • Delay in the enrollment process leads to heavy revenue loss.  

Not completing re-credentialing

You are not credentialed forever with any payer. Usually, you need to get credentialed every three years. You should complete the re-credentialing process on time to avoid laps in your credentialing. Not doing the re-validation or re-credentialing is like you are not credentialed and eligible to get payments from a particular payer.

“Background check is the most important part of the credentialing process. If you don’t do complete this step properly it might cause issues later.”

What are the elements of credentialing?

Elements of credentialing include but are not limited to education, Training, licensure, Work history, Malpractice claim history, Criminal background history, and judgment.

  • Education plays a key role when an individual provider gets credentialed with Payer. The provider must meet the NCQA standard education requirement to get the credentialing application processed.
  • Training is also a key element that the provider should complete the standard Internship/ Residency/ Fellowship in the requested specialty as per the standards.
  • Licensure is another mandatory element in credentialing, the provider should meet the state-mandated license required to practice in the respective state, and the license should be in good standing with no limitations or license actions.
  • Payers will be validating the past 5/10 years of work history, and they can request a reason for any gap that is more than six months, if any. For recently graduated providers, their respective education & training would be considered for work history.
  • If the provider had any Malpractice cases that were proved against the provider, the Payer decides to accept the provider in the network based on the case level.
  • The Payer will validate the provider through federal systems like OIG, SAM, etc., to confirm that the provider is in good standing with no criminal background history.

What are the benefits of credentialing?

The credentialing process is not new. It is 1000s years old and an integral part of the healthcare system. Here are the benefits of credentialing:

Quality assurance

Meeting the standards of credentialing is important for healthcare providers. Credentialing ensures the quality of care and shows how compliant you are toward the line of work. Patients demand high-quality service from the providers they plan to visit for their treatment.

Reduce revenue loss

Credentialing keeps you safe from losing revenue. If you get credentialed with the payers, you will surely get reimbursement for your services unless the claims get denied.

Cater to a bigger patient base

Credentialing helps you cater to larger patients as the patients prefer to get treatment who accept insurance from the company they get registered with. Credentialing helps to gain more patients, which will result in more revenue for you.

Gives you a better reputation

Patients have become smart and more cautious. They now want to know the history of the provider they are considering for services. Credentialed providers have a better reputation, and patients have more trust in them. You look more reliable. Thus more clients come to take services from you.    

What are the benefits of partnering with a third-party service provider for credentialing?

Knowing the credentialing process inside out and having a strong connection with the payers aids you in getting credentialed faster. Third-party credentialing service providers like Plutus Health have immense expertise and experience in credentialing. They can help you seamlessly complete the process and gain maximum benefits.

Plutus Health is an end-to-end revenue cycle management company that has been providing credentialing services for 15+ years. We offer services like individual credentialing, group credentialing, creating CAQH profiles, providing CAQH maintenance, demographics updates, EDI/ERA/EFT enrollment, license maintenance, and more. Click here to connect with our credentialing team to learn more about the process and benefits we can offer with our services.

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Febien Caltin

Febien Caltin is a dynamic professional with 20+ years of extensive experience in the healthcare RCM space. He has expertise in Consulting, and Strategic Planning on solving critical issues healthcare providers face in the RCM process. Febien is committed to the growth of healthcare providers through his immense experience.