CREDENTIALING:

Credentialing is the process of verifying the proven skills, training and education of healthcare providers.  Verification of the providers credentials are done by contacting the “Primary Source”, which has provided the license, training and education.  The credentialing process is used by healthcare facilities as part of their hiring process and by insurance companies to allow the provider to participate in their network.  Credentialing is also the validation of a provider in a private health plan and the approval to join the network.

The process involves the following steps:

• Application Evaluation. Completing required documentation and identifying exceptions.
• Primary Source Documentation. Verify practitioner/ facility information from physicians.
• Outbound Call Center. Obtain missing documents and updating the applier’s database.
• Follow-up with payers. Follow-up on submitted credentialing requests.
• Data Entry. Capture data, label, and link images to specific providers/ facilities in the applier’s database.
• Maintenance of Provider Data. Update provider information as per policies and procedures, and CAHQ profile.

ENROLLMENT:

Enrollment is the process of requesting participation in a health insurance network as a provider.  The process involves requesting participation, completing the credentialing process, submitting supporting documents and signing the contract.  Enrollment is also known as the validation of a provider in a public health plan and the approval to bill the agency for services rendered.

The process involves the following steps:

• Verification of provider information. Contact payers to determine if they have the correct provider information on file before we submit claims.
• Updating practice’s Pay-to address. Validate and update the provider’s pay-to address or the billing address.
• Enrolling for electronic transactions. Our team can enroll providers for four types of electronic transactions:
  • Electronic Data Interchange (EDI)
  • Electronic Remittance Advice (ERA)
  • Electronic Fund Transfer (EFT)
  • CSI
• Monitoring process. A group of highly skilled team members trained to perform research and analysis on the possible processor functionality gaps.

Benefits of Credentialing and Enrollment Services:

With the new diligent credentialing and Enrollment services, you get the following benefits:

• Get credentialed faster with all significant appliers
• Reduce claim denials and improve cash flow
• Get more patient referrals from the network
• Avoid piles of paperwork with our document management system
• Get support for filling up cumbersome application forms
• Reduce costs of the credentialing process with the global delivery teams
• Get timely reports on the status of your applications