The Steps Needed to Become an In-Network Provider

So you’ve decided to become an in-network provider with health insurance companies—congratulations! You’re on your way to growing your practice’s client base and revenue, and also to seeing more patients who may otherwise not be able to afford your services. If you’ve gotten to this stage, you may be vaguely aware that the process actually has two parts: credentialing and contracting. But what do those components mean? How long does each take? And when can you actually officially start seeing patients and filing claims? This blog post will provide answers to your questions.

Credentialing

In your quest to be able to accept health insurance, the credentialing step comes first. You initiate this step with a credentialing application to the payer or payers with whom you’d like to be in network. Depending on the insurance company, this will happen via an online form, an application that needs to be emailed or faxed to a particular destination, or by initiating the process over the phone with an insurance rep.

Initiating credentialing means that you are announcing to the health insurance company or companies in question that you’re a valid, legitimate health care professional. They will proceed to do due diligence to make sure that you are indeed in possession of the credentials you claim to have. The companies will do a thorough review of the documentation they request as part of the credentialing application, which typically includes at least a copy of your W-9, your tax ID, your NPI (or NPIs), your practice name, your service location, and your billing and mailing addresses. They will also review your CAQH profile to further verify your qualifications and background. (We’ve actually had a health insurance company call us to inquire about an employment gap in the work history section of a dietitian’s profile; it needed to be updated to reflect that the dietitian was on maternity leave at the time. Just an illustration of how the company, and a real human within the company no less, is in fact going through your information line by line!)

Some companies also add another step to the mix, by involving a third-party verifier. This additional verification can add an extra two to four weeks to the process. At the end of the verification process, a committee within the credentialing department, generally referred to as a Clinical Review Committee (or the like), will meet to do a final approval of your credentials.

Once the credentialing department and the necessary committee within an insurance company has decided that your background and information checks out, you’ve cleared the first major hurdle. Bravo! The process has probably taken at least 45 business days, but everyone is now in acknowledgement that you have the legal authority to dispense nutrition counseling.

Contracting

The credentialing department has now passed your application along to the contracting department. They may let you know this -- or they may not. This is the sort of thing that Healthy Bytes stays on top of by being regularly in touch with our health insurance contacts.

Contracting encompasses the process of setting up an agreement with a health insurance company that clearly defines the scope of responsibilities. This will likely take another 30 to 45 business days. In that time period, the payer will draw up a contract that is specific to your geographic location, your specialty, and other relevant information. This contract will specify the kinds of services you’ll provide that are designated as reimbursable services, as well as the (non-negotiable) reimbursement rates they have set. The contract will include a starting date from which henceforth you are permitted to see patients and file claims for health insurance reimbursement, known as the effective date. Your contract is official once you have an effective date and a copy of the signed (by you and the insurance company) contract on file.

As you can see, the credentialing is the more involved part of the process to become an in-network provider, but you won’t be able to submit claims until you’ve completed both credentialing and contracting and have a signed agreement on file.