Credentialing with Insurance Companies

We will be doing more Blog Posts on the subject of Credentialing, but today’s is simply an overview for you to understand what it is.

Credentialing, as defined by Texas Administrative Code (TAC) §10.82, is the “process for selection and retention of network doctors and health care practitioners” (providers). Credentialing is the process of establishing the qualifications of licensed professionals, organizational members or organizations, and assessing their background and legitimacy.  The credentialing process is part of the required Quality Improvement Program described in 28 TAC §10.81 and Texas Insurance Code, §§1305.301-1305.304. All certified workers’ compensation networks are required to document, create policies and procedures, and develop written criteria for credentialing network providers.

The initial credentialing process may begin with a provider submitting a completed Texas Standardized Credentialing Application to the Insurance Company and Network in which they wish to participate. The Credentialing Department and/or Committee will verify items such as the applicant’s work history, current professional liability insurance, education, board certification (if applicable), history of loss, sanctions or other disciplinary activity. The process may also consist of an on-site visit to assess the applicant’s location of practice or facility.  The applicant must be notified of the credentialing committee’s decision no later than 60 days after the decision. The WCNet is required to re-credential each participating credentialed provider every 3 years.

Many health care facilities, institutions and providers conduct their own credentialing, through this is a service that can be paid for and done by a credentialing specialist or electronic service, with review by a medical staff or credentialing committee.  It may include granting and reviewing specific clinical privileges, and medical or allied health staff membership.

As Texas is not an “any willing provider” state, the WCNet is not required to contract with a provider applicant. However, pursuant to 28 TAC §10.82, a provider has the right to review the information submitted to support the credentialing application, correct erroneous information and the right to be informed of the status of their credentialing or re-credentialing application.

The process is generally an objective evaluation of a subject’s current licencee, training or experience, competence, and ability to provide particular services or perform particular procedures.

Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment).  Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.

 

Do you do your own credentialing or do you hire someone else to do it?

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