Provider Credentialing and Contracting

Provider credential is the process of getting a physician or a provider affiliated with the payers. Credentialing is a critical step in Revenue Cycle Management because it involves a lot of manual work in terms of completing the application forms, providing clarifications to questions from the payers and following up to complete the credentialing. Further more Apple Billing and Credentialing focus on getting the provider enrolled quickly and to reduce the delay in payments. Apple Billing and Credentialing goal is to simplify the process and reduce the cost. Therefore Apple Billing and Credentialing team will manage the credentialing process from the start until the applications are approved.

  • NPI registration (Type I and Type II)
  • Medicare (PECOS) and Medicaid credentialing
  • Managed care credentialing (Medicare and Medicaid)
  • Commercial insurance credentialing
  • Follow up with the insurance payers until the final credentialing approval
  • Re-credentialing with all the payers
  • CAQH profile creation, maintenance, and re-attestation.
  • Hospital PHO/IPA applications.
  • Payer fee contract negotiation.
  • Medical license and DEA renewals.

CAQH 

CAQH stands for “Council for Affordable Quality Healthcare”. It is an online database that stores provider information. Providers grant access to their information to insurance companies rather than sending information to each insurance company seperatly. Most of the Health Insurance Companies use CAQH and it is a prerequisite for their enrollment process.

CAQH Credentialing process:

  • Creating the new CAQH ID and and maintain the database
  • Complete the application and send in requested documents
  • CAQH profile re-attestation for every three months 
  • Grant insurance companies access to online application
  • Reminders to providers about expiring certificates to re-apply

Provider demo maintenance

Maintaining the practice or provider demographics with the payers is very important when the providers are re-locating, adding satellite locations, specialties, changing the practice phone and fax numbers etc. ABCLLC team will help the transitions without any interruption in service and monthly revenue.

Fee schedule analysis and auditing

ABCLLC will compare the payer contracted fee schedule and actual fee paid every month and detailed monthly audit reports are Emailed. Difference in the payments are checked and reclaimed with interest to the payers.

ERA/EFT services –Getting paid electronically

ABCLLC will setup the EFT payments for the providers in which payer payments deposited directly in the bank which save lots of manual hours to the practice. ABCLLC will also help you to switch the paper EOBs into electronic ERAs.

Credentialing comparison with others

 

Enrollment ABC LLC Others

Credentialing the providers with Medicare and Medicaid

Provider credentialing

Provider credentialing

Credentialing the providers with commercial insurance

Provider credentialing

May be

Provider profile creation and data maintenance with CAQH

Provider credentialing

Provider credentialing

Maintaing the list of in-network and out of network insurances

Provider credentialing

Provider credentialing

PMS setup will be done in 24 hours

Provider credentialing

Provider credentialing

Switching check payments into direct deposit within two weeks
from the date of first check received

Provider credentialing

Provider credentialing

EDI enrollments for claims and ERA will be done with 24-48 hours

Provider credentialing

Provider credentialing

Provider demographics update with the insurance

Provider credentialing

Provider credentialing

Hospital provider credentialing

Provider credentialing

Medicare enrollment

Provider Re-validation with CMS

Medicare enrollment

Medicare enrollment

Provider Re-validation with state Medicaid program

Medicare enrollment

Medicare enrollment

New NPI application for the group practice and individual
providers within 2 hours if needed

Medicare enrollment

Medicare enrollment

Adding additional service locations with the insurance

Medicare enrollment

Medicare enrollment

Enrolling the providers with state Medicaid CMO plans

Medicare enrollment

May be

Notification to the providers with the expirable
documents and professional certificates

Medicare enrollment

Medicare enrollment