Missing Piece Blog

Contracting and Credentialing for Beginners

What is the difference between credentialing and contracting?

Contracting is the process of becoming in network with a payer. When complete, both you and the payer will sign the contract which outlines the conditions or terms of the agreement and obligations of each party.  As a provider, it is critical that you understand your obligations to the payer.  Each payer’s contract is very different, and your obligations may be as well.  Be sure you understand these and seek guidance from professionals as needed. Some payers will offer group contracts, and some offer individual contracts with behavioral health and ABA providers. 

Credentialing is the process that payers use to verify a provider’s credentials, and to ensure that they meet the standards required by that payer to render services; this may include documents such as licenses or certification, and professional liability insurance. Each payer will have different standards that providers are required to meet.

What is an NPI number?

NPI stands for National Provider Identifier.  This is a number that is used to identify either an individual or a group healthcare provider.  These numbers were established as an alternative to the use of Social Security numbers as an identifier, and are required to bill claims. The NPI registry is managed by the US Centers for Medicare and Medicaid and the Department of Health and Human Services.  Having an NPI number does not guarantee that the provider or organization has valid licensing or certification. It is simply an assigned number used for identification purposes. 

Individual providers should keep in mind that the Type 1 NPI will stay with the provider regardless of employment, so the individual provider is responsible for retaining their login and password information to maintain their NPI profile.  The set-up process to obtain a NPI number is relatively quick.  To establish a Type 1 NPI number or individual NPI, a provider will need the following information:

  • Full name
  • Telephone number (business and personal)
  • Date of birth
  • Social security number
  • Home address
  • Email address
  • Taxonomy code

A Type 2 number should be established only for a group or business entity.  A business may need one or many NPI numbers.  Refer to NPPES for more information.  In general, a business will need the following information to establish the NPI number(s):

  • Legal Business Name
  • DBA (Doing Business As) Name
  • Legal Address
  • Phone Number
  • Tax Identification number
  • Email address
  • Taxonomy code(s)

For more information or to enroll, refer to: https://nppes.cms.hhs.gov/#/

What is CAQH?

CAQH stands for Council for Affordable Quality Healthcare.  This is a non-profit organization established to streamline healthcare credentialing by creating a database for providers to house credentialing documents that payers can access. Prior to the creation of CAQH, providers would have to complete numerous extensive applications for each payer, ultimately repeating similar information on each form. 

A provider can either set up their own CAQH profile, or it can be created on their behalf.  The CAQH information and identifying number will remain with the provider regardless of employment; therefore it is important for the provider to be knowledgeable about their account and login information.  This information may change as employment changes, and will need to remain current.  To set up CAQH credentialing for the first time, a provider will need the following information:

  • Full Name
  • Address
  • Personal Phone Number
  • NPI number
  • License or certification information
  • Employment information
    • Address
    • Tax ID
    • Group NPI
    • Practice Locations
  • References
  • Educational Background including degrees and locations of schools attended
  • Prior Employment History including locations, as well as, explanation of employment gaps of six months or more
  • Professional liability insurance information and face sheet
  • Taxonomy code

To set up or access CAQH: https://proview.caqh.org/Login?Type=PO

How do I get started with contracting and credentialing with payers?

Contracting and credentialing can become a very time-consuming and overwhelming process.  It can take from 30-180 days or more — depending on the payer — and requires intensive follow up. The information that makes up the contracts and credentialing effects every claim that is billed. If something is incorrect, the claim will be denied which will lead to more time and money being spent to correct the contracting process.

Missing Piece has helped hundreds of providers with their contracting and credentialing needs.  Whether it is strategizing with you about your network’s status, or providing guidance through fee scheduled negotiations, we are here to help maintain and keep your payer group contracts in the most current status possible. We know firsthand that contracting and credentialing require extensive documentation and follow-up. Let Missing Piece come along side you during this process and take care of all the details to help provide  give you peace of mind that everything is done quickly, efficiently, and correctly to ensure you receive your reimbursement as soon as possible.

Contact us today at

765-628-7400 or weare@yourmissingpiece.com

to discuss our comprehensive revenue cycle management process to learn more about all the ways Missing Piece can help your organization.

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