Credentialing Resources

Helpful Links

FAQs

  • How much time will it take before our credentialing process is complete?

    Whether you start a solo practice or join a large multi-specialty group, there are several steps to complete. The process will take additional time if you have never been credentialed individually or with another group. It will also take more time if you are applying with a new payer or a new Medicare fiscal intermediary.. Maintaining all your credentialing documents [certificates, diplomas, licenses, registrations, ECFMG Certificate, CAQH user name & password, NPI username & password, etc.] in one location and keeping this information updated is the first step to completing the credentialing process. Most payers take approximately 90+ days to process your application once they receive completed and accurate information and documentation.

  • When can I start submitting claims?

    You can begin submitting claims when you receive the effective date from insurance payer.

  • Why does the credentialing process take so long?

    The entire process takes 90 to 120 days from the time that the insurance payer receives ALL of the payer-specific information and documents. Delays can be experienced throughout their “verification process”. For example: when calling the university where you went to medical school, if school is in recess, it takes longer to obtain the information and documentation requested. Once information is received by the payer, it must go before their Credentialing Committee. If the committee already met for that month, your application will be delayed until the next committee meeting, which may be another month away.

  • Can we bill for services performed before the process is completed?

    No. You must wait until the effective date to submit claims. Claims submitted for services rendered before the assigned effective date will be denied and/or paid as out of network.

  • What is an Internal Revenue Service (IRS) CP-575 Form?

    The IRS CP-575 form is the letter sent to you assigning your Federal Tax ID Number (“TIN”).

  • I donʼt have a copy of the CP-575. Is there a way to get a copy of this or

    is there an alternative document that is acceptable?

    Usually your accountant or lawyer, or whomever applied for your Tax ID Number, has a copy. If you do not have a copy, a duplicate can be requested.

  • What documentation must a provider submit with the CMS Form 588

    Electronic Funds Transfer (EFT)?

    The documentation that must accompany a CMS Form 588 is as follows:

    (1) A voided check with the practice legal name and address printed on the check, including account number and tracking number

    (2) The bank address, contact person with title, phone number and the type of account (checking or savings)

  • My Medicare provider number has been deactivated. What does this mean and how do I re-enroll?

    If your Medicare provider number has been deactivated, it probably means that a claim for services hasn’t been submitted for an extended period of time. To re-enroll, new enrollment applications need to be completed.

  • Who are the owners of my organization?

    Anyone with 5% or more controlling interest must be listed on the application. If another corporation owns your facility, then that information must be disclosed. If your facility is non-profit with no defined owners, state this in Section 6 and complete the section for all board members.

  • Who is a managing/directing employee?

    A managing/directing employee is defined as any employee who has day-to-day control over the organization, including hiring and firing capacity. This section should include, but is not limited to, general manager(s), business manager(s), administrator(s), director(s) and board of directors. For large business organizations, only the top twenty compensated managing/directing personnel should be listed. Social Security numbers must be provided for all persons listed in this section.

     

  • What constitutes an Authorized Official on a CMS-855 enrollment form?

    An authorized official is defined as an appointed official (e.g. chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.

     

    The authorized official must be an owner or officer of the enrolling facility and not only of an owning organization. CMS has clarified that the chain home office administrator of the chain organization to which the provider is affiliated does not automatically qualify as the authorized official by virtue of this role.

     

    The authorized official must have a position or ownership with the enrolled/enrolling facility. The organization can have as many authorized officials as it wants as long as each person meets the definition. In addition to meeting the requirements listed in this paragraph, a new authorized official must be listed in Section 6 – Ownership Interest and/or Managing Control Information (individuals) of the CMS-855A application.

CAQH

The CAQH Universal Provider Datasource (UPD) service is the industry standard for collecting provider data used in credentialing, claims processing, quality assurance, emergency response, member services, such as directories and referrals, and more. By streamlining data collection electronically, UPD is reducing duplicative paperwork and millions of dollars of annual administrative costs for more than 700,000 physicians and other health professionals, as well as over 500 participating health plans, hospitals and healthcare organizations.

 

NPPES

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.

 

NPI Registry

The NPI Registry enables you to search for a provider's NPPES information. All information produced by the NPI Registry is provided in accordance with the NPPES Data Dissemination Notice. Information in the NPI Registry is updated daily. You may run simple queries to retrieve this read-only data. For example, users may search for a provider by the NPI number or Legal Business Name. There is no charge to use the NPI Registry.

 

 

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