User Guide — Credentialing

 

When a provider is credentialed with a payer, the provider is generally considered a participating provider. Many practices perform credentialing themselves, working directly with the payers or by contracting the work to a third party. The credentialing process involves compiling and verifying personal and professional information. Additionally, the provider must frequently update and attest to this information.

 

Note: The credentialing process is separate from payer enrollment. Credentialing is limited to providing a payer with information to verify a provider's professional standards, whereas payer enrollment allows a provider to start billing a payer and exchanging electronic data with the payer.

 

For the credentialing process, two categories of information are required from a provider: personal information and professional information.

• Personal information required for credentialing includes items such as name, address, contact phone numbers, NPI, and tax IDs.
• Professional information required for credentialing includes documents such as medical licenses, state board certifications, employment history, and verification from an insurance provider of medical malpractice coverage.

After the credentialing information is compiled, the provider must submit the information and supporting documents either electronically or on paper to the payer.

 

athenahealth can provide some co-sourcing support as you credential on your own (see Credentialing Co-Sourced).

 

 

With co-sourcing, your practice is responsible for credentialing your providers (see Credentialing Co-Sourced). Your staff must work with payers to provide the documentation that they require to issue provider numbers. athenahealth will confirm during what we call "provider enrollment" that your provider numbers in athenaOne are correct and that they are linked to your group and submitter numbers. athenahealth will also confirm the address to which the payer sends payment and remittance advice (if it's on paper) for that physician.

 

Your practice is responsible for establishing and maintaining contracts with payers. Credentialing is confidential information between a provider and payer. It is against industry policy for a payer to release this information to anyone outside the provider's office. Payers use this information to confirm that partners such as athenahealth have been authorized to discuss claims on behalf of the provider. For this reason, athenahealth will ask you at certain times to contact the payer and verify or update specific information.

 

Accurate enrollment directly affects the quality, accuracy, and efficiency of the work that athenahealth performs for your practice: eligibility transactions, claims, and electronic remittance all depend on correct enrollment to help ensure that your practice is paid promptly and correctly.