By: Ann Knutson, CPC-A
Facility credentialing is a critical aspect of healthcare revenue cycle management. This is the process in which an insurance carrier evaluates a facility for approval to be ‘in network’ and a participating provider of specific healthcare services. According to the Minnesota Department of Health:
“Credentialing is the process used to determine if an individual practitioner and/or provider organization is qualified and competent to deliver acceptable medical care. An individual practitioner and/or provider organization is credentialed when they apply for participation in an insurance network and every three years thereafter.”
(https://www.health.state.mn.us/people/immunize/hcp/billing/contracts)
The process can be a lengthy and arduous one – facilities need to begin the credentialing process at least 120 days before expecting any payments from an insurance carrier to receive ‘in network’ reimbursement. Usually, it takes 90 days to complete the credentialing of a facility, but it can take up to 120 days or even longer.
The usual medical organizations eligible for facility credentialing include:
- Hospitals
- Home Health Agencies
- Freestanding Surgi-centers
- Sleep Medicine Centers and Labs
- Skilled Nursing Facilities
- Community Mental Health Centers
- Hospice Centers
- Ambulance
- Birthing Center
- Clinical Lab
- DME
- Residential Substance Use Disorder Facility
- Pharmacy
- Dialysis Center
- Rural Health Clinic (RHC)/Federally Qualified Healthcare Center (FGHC)
To begin the process of credentialing most insurance carriers require a facility to submit an application for a contract. A few insurance carriers will request additional documents with the application. Conversely, others will wait until the credentialing process begins. Once a contract has been offered, then the credentialing process begins with completing a facility credential application. Other documentation will be requested by the insurance carrier, such as:
- A Facility License issued by Minnesota (i.e. 245G License)
- Any Certification (i.e. JCAHO certification or CARP certification)
- Any Accreditation
- Certificate of Liability Insurance (Professional and General Liability)
- License issued by the MN Department of Health
- MN Uniform Facility Credentialing Form
- W-9 Form for the Facility
- Ownership and Control Interest Disclosure Statement
- MNDHS Approval Letter (if accepting MA insurance)
- Medicare Certification Documents from CMS (if accepting Medicare)
- Building Inspection Certificate
- Fire Marshall Inspection Certificate
- Lodging License (if needed)
- EFT/ERA Applications
- Miscellaneous documents required by certain insurance carriers (i.e. Staff Roster, Facility Rate Sheet, Model of Care Summary, Provider Information Form)
To make the credentialing process easier, faster, and more efficient, Blue Cross and Blue Shield of Minnesota, HealthPartners, and Medica health plans decided to use the web-based credentialing app called The Minnesota Credentialing Collaborative (MCC) to submit the credentialing application. It is only necessary to complete the application once and submit it to multiple insurance carriers. (https://www.health.state.mn.us/people/immunize/hcp/billing/contracts.html)
Once all required paperwork and documents have been submitted, the insurance carrier’s credentialing team will review them and make a decision. This part of the process can take anywhere from 90 to 120 days or even longer depending on if there is a backlog or not.
If the facility is approved and accepted into the insurance carrier’s network, then an effective date of the contract will be assigned to the facility. Finally, a completed and signed contract with the effective date on it will be sent to the provider at the facility. When this is received the facility is able to provide services to members of that particular insurance carrier and submit claims for ‘in network’ reimbursement.
Since facility credentialing can be a daunting and time-consuming process, contact MedCycle Solutions to complete the process for you.
Ann Knutson, CPC-A is an Accounts Receivable Specialist at MedCycle Solutions, which provides Revenue Cycle Management, Credentialing, Outsourced Coding, and Consulting Services to a number of healthcare providers in a variety of specialties. To find out more about MedCycle Solutions services please visit www.MedCycleSolutions.com.