What Is Credentialing and How Does It Differ from Provider Enrollment?


One of the most frequent questions that our partners ask us is if credentialing and enrollments are the same thing. The fact of the matter is, credentialing is vastly different from enrollments, and they have key factors that set them both apart from one another. The most notable difference can be found in the submission and claims process.

What is credentialing?

Credentialing is best known by most medical practice owners as their “background check” that is completed by one of many insurance companies that they do business with. These companies need verification of the experience, training, and certification of the medical credentialing services as well as a way to measure the quality of care that they offer. This happens once a provider registers with an insurance company’s system along with presenting their NPI.

The process of credentialing varies depending on the payer, however, there is an important step in order for the payer to get reimbursement for the services issued to them. This process can either be completed in the form of paperwork or online, but online is preferable, and if that isn’t an available option, then providers are left with completing the paperwork. Once the application is submitted, then the insurance company will confirm the provider and conclude the credentialing process.

Credentialing, unlike with enrollments, is directly handled between the medical credentialing services and insurance companies. These credentialing services do not in any way change the process that is required of these insurance companies. When dealing with each insurance company, however, medical credentialing services can help you contact each one’s provider enrollment department so that you can learn more about credentialing for each company faster and be able to get through each step in the credentialing process quicker as a result.

What is enrollment?

Before providers can start to see patients and offer them the required care and services, they first must be enrolled with insurance or health care plans in order to be considered “in network”. It is not a requirement to be enrolled with healthcare plans to get into medicine, but there are not as many patients out there that will decide to pay “out of network” prices for a service provider who is not enrolled, when they already pay for insurance in monthly premiums. So, if a patient has insurance, they will hope to have their company pay for your services.

In order to be listed as an “in network provider”, the provider must get enrolled with the insurance company’s health plan. To become enrolled, the provider will often need to get credentialed, which means certain criteria must be met in order for the insurance company to approve the provider.

When the insurance company commences the enrollment process, the next steps are to be determined, but oftentimes, the payer must be credentialed along with the provider. There are complexities that you must overcome during the enrollment process, but you typically don’t get any guidance from the credentialing services. Instead, a provider enrollment specialist from the insurance company helps you know what to expect. The provider will need to know many different details about you and your medical practice, including whether or not you already have contracts in place with other insurance companies.

Insurance companies typically don’t disapprove of working with hospitals that also work with competitors, but rather they prefer insurance companies that already have a list of insurance partners to ensure that your practice is reputable. If you are a startup company with no known insurance partners as of now, credentialing with insurance companies will likely be your better option.

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