If your private practice intends to accept insurance, you must be credentialed with each individual insurance company that you are “in-network” for. Credentialing with insurance payers can be a lengthy process, but by planning ahead you can navigate this landscape and open your doors to a wider range of clientele.
In this article, we will cover the basic steps to credentialing and answer common questions about the process.
What is credentialing?
Credentialing is the process insurance companies, or payers, use to determine if a provider and/or organization is qualified and able to deliver quality medical care at reasonable costs.
What are the benefits of credentialing?
There are several advantages to being credentialed with one or more insurance payers. When you are “in-network” or a participating provider, you are eligible for reimbursement from a payer at negotiated rates. Given that 316 million people in the U.S. (92.3% of the population) have health insurance coverage, being credentialed also allows you to reach a much larger audience who may otherwise not be able to afford your services.
How often do I need to credential with an insurance payer?
A provider and/or organization is credentialed when they apply to participate in an insurance network, and must re-credential every two to three years.
How do I get credentialed?
Step 1: Understand the Requirements
Before you start, familiarize yourself with the specific requirements of the insurance companies you wish to work with. Each insurer may have different criteria, including educational qualifications, licensing, and experience. Common requirements include:
Valid state licensure (LCSW, LPC, PsyD, etc.)
Educational credentials (degrees, certifications)
Professional liability insurance
Continuing education credits
Step 2: Prepare Your Documentation
Gather all necessary documents to streamline the application process. Typical documents you’ll need include:
Resume/CV: Highlight your education, training, and relevant experience.
Licensure verification: Proof of your state license and any additional certifications.
Malpractice insurance: A copy of your current policy.
References: Professional references who can vouch for your qualifications.
Step 3: Research Insurance Companies
Create a list of insurance companies you want to contract with. Research their provider directories to see if they accept new providers and what their application processes entail. Pay attention to:
Types of plans offered (HMO, PPO, EAP, etc.)
Reimbursement rates for your services
Application deadlines and any specific requirements
Step 4: Complete the Application
Once you’ve selected the insurance companies, visit their websites to find their provider application forms. Some companies may require you to apply through a portal, while others may provide paper applications. Fill out the application carefully, ensuring that:
All information is accurate and complete
You attach all required documents
Step 5: Submit Your Application
After you’ve double-checked your application and documents, submit them according to the insurance company’s guidelines. Be sure to keep copies of everything you send, along with proof of submission (like confirmation emails).
Step 6: Follow Up
After submission, it’s important to follow up to check on the status of your application. A few weeks after submitting, contact the insurance company’s provider relations department to confirm receipt and inquire about the timeline for credentialing. Be polite but persistent—this can help keep your application on their radar.
Step 7: Complete Any Additional Requirements
During the credentialing process, you may be asked to provide additional information or clarify details on your application. Respond promptly and accurately to any requests to avoid delays.
Step 8: Await Approval
Once your application is complete and all information has been verified, you’ll receive a notification regarding your credentialing status. This can take anywhere from a few weeks to several months, depending on the company. If approved, you’ll receive details on how to bill for services and access to their provider portal.
Step 9: Contracting
If your application is approved, you’ll likely need to sign a contract with the insurance company. Review the terms carefully, especially regarding reimbursement rates and billing procedures, before signing.
Step 10: Stay Updated
Once you’re credentialed, make it a habit to keep your information up to date. Notify insurance companies of any changes to your licensure, contact information, or practice details. Also be aware of re-credentialing requirements for each payer.
What if an insurance company isn’t accepting new providers?
It can be frustrating when an insurance payer is full, but you do have some options:
Check Back Later: Insurers often have periods where they pause accepting new providers. Keep an eye on their website or contact their provider relations department for updates on when they might reopen their network. Set quarterly reminders on your calendar to check in with payers.
Explore Other Insurers: If your preferred payer isn’t accepting new providers, consider applying to other insurance companies. Broaden your search to include local and regional payers, as well as specialty networks that may align with your practice.
Join a Group Practice: Sometimes, individual practitioners face challenges getting credentialed. Consider joining a group practice or network where existing providers may already have contracts with payers. This can sometimes allow you to get credentialed under their existing contracts.
Utilize Out-of-Network Benefits: If you're unable to join a specific insurance plan, consider informing potential clients that you can work with them as an out-of-network provider. This allows clients to submit claims for reimbursement, even if you aren't directly contracted with their insurer.
What if I get denied by an insurance payer?
An insurance payer may choose to decline your application. Don’t get discouraged, and do the following:
Request Feedback: If your application is denied, reach out to the insurance company for clarification on the reasons for the denial. Understanding the specific issues can help you address them effectively.
Address Concerns: Once you receive feedback, take the time to correct any deficiencies in your application. This might involve providing additional documentation, clarifying your credentials, or meeting any specific requirements they outline.
Appeal the Decision: Most insurance companies have an appeals process for denied applications. Familiarize yourself with the process and submit a formal appeal if you believe the denial was unfounded. Include any supporting documents and a clear explanation of why you believe your application should be reconsidered.
Consider Reapplying: If your appeal is unsuccessful or if there are significant barriers to acceptance, you can choose to reapply after addressing the issues that led to the denial. Ensure you’ve made the necessary improvements to strengthen your application.
Seek Guidance: Consider reaching out to colleagues who have successfully navigated the credentialing process. They can offer insights, advice, or even referrals to credentialing consultants who can assist you in improving your application.
Where do I find information about joining a payer network?
Searching your desired insurance payer’s name plus the terms “contracting inquiry”, “credentialing”, or “join network” can help you find information on their websites regarding contracting and getting in-network. Remember that every payer’s process may differ slightly.
Getting credentialed with insurance companies can be a complex but rewarding process. By following these steps, you’ll be well on your way to expanding your practice and providing essential mental health services to clients who rely on insurance coverage. Remember to be patient and thorough, and best of luck!
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