Whether you’re starting a new practice or you’re adding additional practitioners to your clinic, they all have to go through the physician credentialing process.
what is needed to establish payer contracts
New Practice
Adding a New Provider to Group
Adding a New Provider to Group
STEP BY STEP
Establish a new group in your state, and acquire your Tax ID information from the IRS.
Download the e-file (CP-575) when gathering the information on your EIN.
Provide the address where your practice is located. Since you are already established as a private medical practice, this information will be easy to implement.
Upon completing the previous steps, you can then apply for a Group NPI.
Next, be sure to update your attested CAQH profile with your CAQH ID.
Identify the payers you’re looking to credential with, including commercial PPOs or HMOs, Medicare, Medicaid, Worker’s Compensation, Tricare, or any other payers around you that you may encounter at your practice.
Develop a W9 form with your billing address.
Since hospital credentialing will be required for various specialist services, and will be required by insurance providers for credentialing, ensure that the credentialing process is in progress with local hospitals or have a covering provider or hospitalist group secured for hospital admissions.
Provide a permanent office phone and fax number to be included on your CAQH and other applications.
Develop a malpractice policy, as this is a requirement for most insurance companies.
As you’re updating your CAQH, be sure to authorize access to your profile for applicable insurance companies.
If you’re looking to apply with Medicaid, you will need a business license, articles of incorporation, group/practice liability insurance and worker’s compensation insurance, CLIA certification or waiver if applicable.
Once all of these steps are in place, you will be able to submit letters or interest or applications to payers that you are hoping to utilize at your practice.
Adding a New Provider to Group
Adding a New Provider to Group
Adding a New Provider to Group
STEP BY STEP
Provide an updated and attested CAQH profile, with new practice affiliation (including start date) listed. Additionally, the provider’s license and DEA must also be updated with the new state they’ll be working in if this is different from their initial affiliation.
The group the provider will be added to will need to supplement a list of payers they are currently affiliated with, including commercial, Medicare advantage, Medicaid HMOs, worker’s compensation, Tricare, as well as any TPAs.
Supply Tax ID to insurance companies and update your CAQH profile with this information as well.
As hospital credentialing is necessary for some insurance payers or specialty providers, the list of hospitals you intend to have privileges with will need to be updated in your CAQH profile. If you don’t intend on having hospital privileges for your practice, you will need to create an admitting arrangement with a provider, or decide which hospitalist or ER in your area you will be utilizing for admitting arrangements.
Provide new or updated malpractice policy and update in your CAQH profile.
Provide the group’s primary billing type, which will be listed on applications with Tax ID.
Provide the group’s Medicare PTAN that you plan to be included on, which will be listed on your Medicare application linked to the new group.
Additional Documents Required
Adding a New Provider to Group
Additional Documents Required
CP575 OR 147C Letter
Signed and completed W9 form
Business license
(If required in your state) Fictitious name permit
Articles of incorporation or organization
Liability insurance coverage
Worker’s compensation insurance coverage
CLIA certification or waiver
EFT verification from your bank or a voided check
Professional license
DEA certification
CDS certification
Board certification or proof of eligibility
PLI certification
Professional school diploma
Certification of completion for internships, fellowships, or residencies
CAQH login and password
PECOS login and password
State Medicaid login and password
Availity system login, password, and backup codes
Current CV with exact beginning and ending dates
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