Insurance Credentialing: Navigating A Move To A New Location

If you're a healthcare provider who has relocated or is planning to relocate to another state, you'll need to go through the insurance credentialing and contracting process again for your new practice location. This is because insurance credentialing is linked to your practice location, and each state has different insurance networks and requirements. The first step is to contact the network provider services department of the insurance company to inquire about their credentialing process and obtain a credentialing application. The credentialing process can be time-consuming and typically takes anywhere from 60 to 180 days for each carrier, so it's important to start early.

Understand the credentialing process

Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy. It is a formal process that ensures patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine. Credentialing is also defined as the process of granting a designation, such as a certificate or license, by assessing an individual's knowledge, skill, or performance level.

In the healthcare industry, credentialing is a vital process that ensures healthcare institutions provide competent and safe care to their patients. It involves verifying the academic qualifications and clinical practice history of a healthcare provider. This includes verifying many elements such as licensure, education, training, experience, competency, and judgment.

The process of credentialing typically consists of two phases: credentialing and contracting. The credentialing phase is when the insurance company verifies all your credentials and ensures you meet their requirements for participating in their network. The contracting phase is where the company issues a participating provider agreement that defines the terms of participation for receiving in-network reimbursement for your claims.

The credentialing process can be time-consuming and may take several months to complete. It is important to understand the steps involved in the credentialing process to ensure a smooth and efficient experience. Here are the key steps to understand:

• Information Gathering: The healthcare facility or insurance plan requests information from the provider, including background, licenses, education, etc. This information is typically submitted through a questionnaire or software.
• Information Verification: The facility or insurance company verifies the provider's information by directly corresponding with licensing agencies, medical schools, and other entities. They may also use credentialing software to continuously check information.
• Credential Awarding: After verifying all required credentials and finding no negative issues, the healthcare facility awards credentials to the provider. The insurance company may then approve the provider as an in-network provider.

It is important to note that each state has its own unique laws and requirements for credentialing, and the process may vary depending on the type of provider (physicians, physician assistants, nurses, etc.). Additionally, credentialing is often required for specific procedures or specialties within a healthcare facility.

When relocating to a new state or practice location, healthcare providers must typically start the credentialing and contracting process from the beginning, even if they participated with the same insurance networks in another state. This includes enrolling with Medicare, Medicaid, and other insurance networks specific to the new state.

To ensure a smooth credentialing process, it is recommended to maintain accurate and up-to-date records, establish relationships with key personnel, and stay organized throughout the process. By understanding and effectively navigating the credentialing process, healthcare providers can establish their legitimacy and provide the best possible care to their patients.

Contact the insurance company

Contacting the insurance company is the first step in updating your insurance credentialing to a new location. The process will vary depending on the insurance company and whether you are changing locations within the same state or moving to a different state.

If you are moving to a new state, you will need to submit a new enrollment package and obtain new provider numbers. This is because each state has its own contractor for administering Medicare, and your previous enrollment record will not be transferred automatically. You will also need to enroll your business entity and yourself personally to obtain new provider numbers. This process can take some time, so it is important to allow for 60-90 days for Medicare to complete your enrollment application.

For Blue Cross Blue Shield (BCBS), each state has its own association, and your contract will not travel with you if you relocate. You will need to undergo credentialing with the new state's BCBS association and obtain a participating provider agreement. Again, this process can take some time, so it is recommended to allow 90-120 days for completion.

For commercial insurance, most insurance networks will require new credentialing and contracting when you relocate. There are a few national PPO networks that may only require a new contract to be issued, but most companies will require you to be credentialed as a new applicant in your new state of practice. Commercial insurance credentialing and contracting are typically completed within 120 days.

If you are moving within the same state, you may still need to update your insurance credentialing information. The process will depend on the specific insurance company, but some common steps include:

• Contacting the insurance company's credentialing department, also known as Provider Relations or Network Management.
• Requesting a copy of your contract and asking about updating your credentialing information.
• Following any specific instructions provided by the insurance company, such as completing a specific form or submitting an update through their provider portal.
• Providing any required documentation, such as an NPI-1, NPI-2, EIN, and a W-9.
• Following up with the insurance company to ensure your request has been received and is being processed.

It is important to note that the average credentialing time is 60-180 days, so it is recommended to start the process early and allow for sufficient time for processing.

Prepare the necessary documents

When changing your insurance credentialing to a new location, you will need to prepare a variety of documents. The specific documents required will depend on the type of provider and insurance plan. Here is a list of documents that may be needed:

Core Documents for an Individual:

• Practitioner License(s)
• Malpractice Insurance (Certificate of Insurance)
• DEA (federal) and state CDS certificates
• Board Certification(s)
• Copy of the highest level of education (diploma) – required for non-MDs and DOs
• Current CV (showing current employer, and all entries in mm/yy format)
• Current driver’s license

Other Documents that May Be Applicable:

• ECFMG Certificate (if educated outside of the US)
• Passport or other citizenship documents (if born outside the US and not previously enrolled in Medicare)
• Collaborative Agreement (required for Nurse Practitioners)
• Admitting Arrangement letter (required for providers without hospital admitting privileges)
• Prescribing arrangement letter for providers not holding a DEA certificate

Documents Needed for Your Legal Entity:

• IRS form CP575 or replacement letter 147C (verification of EIN)
• Copy of office lease (required for therapy facilities)
• Letter of bank account verification (for Medicare enrollment)

It is important to note that the credentialing process can be time-consuming and may take several months to complete. Therefore, it is recommended to start the process early and have all the necessary documents organized and easily accessible.

Submit the application and documents

Once you have gathered all the necessary documents, you can submit your application. This can be done online or through paper forms. It is important to follow the instructions provided by the insurance company and to include all the required documents. Here are some key steps to keep in mind:

• Completely fill out the application: Take time to carefully and accurately fill out the application form. Make sure to list all the service locations for your practice and include all the necessary signatures and dates.
• Include copies of all required documents: Along with your application, you will need to submit supporting documents. These typically include licenses, insurance policies, board certifications, and other relevant certificates.
• Retain a copy of your completed application: Before submitting your application, make sure to keep a copy for your records. This will help you refer back to the information provided and ensure consistency in case of any follow-up requests.
• Verify receipt of your application: Contact the insurance company to confirm that they have received your application. It is important to follow up regularly until your credentialing process is complete.
• Respond to additional information requests: The insurance company may request additional information during the review process. Respond promptly to any such requests to avoid delays in the processing of your application.
• Document all follow-up activities: Keep a record of all your interactions with the insurance company, including any phone calls, emails, or correspondence. This will help you track the progress of your application and address any issues that may arise.

It is important to note that the credentialing process can take several months to complete, and you may need to follow up regularly to ensure your application is progressing. Each insurance company may have slightly different requirements and processes, so be sure to carefully review their instructions and guidelines.

Follow up on the application status

Following up on your application status is an important step in the credentialing process. The time it takes to hear back about your application can vary, but it's generally recommended to follow up 7-10 days after submitting your application, and then every 15-30 days after that until you receive a response.

• Keep a record of all your follow-up activities.
• Contact the insurance company to verify that they have received your application.
• Respond promptly to any requests for additional information.
• Be prepared to re-submit your application if necessary.
• Update your National Plan and Provider Enumeration System (NPPES) profile and Council for Affordable Quality Healthcare, Inc. (CAQH) profiles with your new practice information.
• If you don't hear back about your application status, reach out to the insurance company directly.
• If you're unsure about your current credentialing status, ask the person handling credentialing at your organisation or contact the insurance company directly.
• If you're waiting on a credentialing decision from Medicare or Medicaid, be aware that these applications can take several months to process.

Frequently asked questions