Before You Start Credentialing: The Paperwork to Get in Order First

Credentialing has a reputation for being slow, and often that reputation is earned. But when you look at why a particular file took longer than it should have, the cause is often not a mysterious payer or a complicated rule. It is a missing certificate, a license that expired last month or a work history with a hole in it that nobody explained.

The good news is that this part is almost entirely in your control. An hour spent getting the paperwork in order before you start can save weeks later.

What to pull together

Requirements differ between payers and hospitals, so treat this as a solid starting point rather than a promise of what any one organization will ask for. For most providers you will want the state license number and its expiration date for every state they practice in, the NPI number, and the DEA registration if it applies to them. If the provider is board certified, have that certificate handy too.

You will also need the education and training history, a current CV, and the certificate for professional liability insurance. Alongside the provider's documents, have the practice details ready: tax ID, addresses and a contact person. It sounds basic, but the practice details are where many mismatches start.

Three mistakes that come up again and again

The first is the expired or nearly expired document. A license that is valid on the day you gather it can lapse before the application is reviewed. Look at every expiration date and ask yourself whether it will still be valid two or three months from now.

The second is the unexplained gap. Time away from practice happens for plenty of ordinary reasons, such as moving, family, further study or illness. Reviewers will ask about it. If you put a short, honest line in the application, it usually ends there. If you leave it blank, you get a question, a wait and a delay.

The third is inconsistency. If the provider is Robert on the license, Bob on the CV and R. James on the malpractice certificate, someone has to stop and work out whether these are the same person. Pick the name as it appears on the license and use it everywhere.

Keep one folder per provider

This is the least exciting advice and the most useful. Give every provider one folder, shared with whoever handles credentialing, with current copies of everything inside. Next time a payer asks for a document, you are not hunting through email. When a license renews, you swap the file and note the new date.

Credentialing is not the same as enrollment

People use the two words as if they mean the same thing. Credentialing is the verification of a provider's qualifications. Enrollment is registering that provider with a payer so claims get paid. Many payers want both, and they often run side by side, which is one more reason to have the paperwork ready.

We keep a free checklist on our Resources page. And if you would rather not do this yourself, take a look at what we handle, or schedule a short meeting and tell us where you are stuck.

This article is general information, not legal or financial advice. Requirements vary by state and payer.

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