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Credentialing and Contracting 101 - What You Need to Know

Are You Venturing Out On Your Own? Here Are Some Things to Know Before You Start the Credentialing Process.

Have you thought about or have decided to venture out on your own? Whether you plan on doing some independent contracting work for yourself or opening up an agency, you will need to take some steps with the insurance companies to get you all square way.

What is Credentialing and Why is it Important?

Credentialing pretty much means "the process of getting you loaded into the insurance companies system". For claims to be processed for reimbursement and authorizations to be approved, you must first be credentialed in their system.

What is the Difference Between Credentialing and Contracting?

These two terms are usually used indeterminately (I mean.. I do it too), but technically these are two separate things. As I mentioned above, being credentialed means you are loaded in the insurance company's system. Normally when you are only credentialed, it means you are out of network with the insurance company. Now, contracting is the process of becoming a contracted with the insurance company. Being a contracted provider means you have a fully executed contract between yourself (or group) and the insurance company and are considered to be an in-network provider.

How Do I Know if I’m Already Credentialed or What my Status is?

You should contact the insurance company directly. Have your NPI number ready and ask them if you are a credentialed provider. If you are, you can ask them if you are credentialed under a group contract or if you have an individual contract. This is important information to know.

What is the Difference Between an Individual Contract and a Group Contract?

A Group contract is where your agency “group” is contracted with the insurance company. You are able to credential providers underneath your group contract. This is the best contract to obtain (if possible) because the contract will stay with your group indefinitely.

Now, some insurance companies only allow individual contracts (i.e. Blue Cross Blue Shield of Florida). In the event that you individually contract your BCBA’s to provide services and link them to your group, and they decide to leave your practice for new employment, the contract will go with them and you will no longer have a contracted Blue Cross Blue Shield provider. Again, this is not ideal but some insurance companies do not allow group contracts.

What should I have before I start the credentialing process for my new agency?

· Completed CAQH profile

· Professional Liability Insurance

· Phone and Fax number

· Business Bank Account

What is a CAQH profile?

A CAQH profile is a free online profile that insurance companies use to credential and re-credential providers. If your provider does not have a CAQH profile, they should complete one before starting the credentialing process. Many of the insurance companies require that the provider have a CAQH profile as part of the credentialing process. This profile is unique to each provider and will stay with them as long as they practice. Please be sure that your provider knows to keep their CAQH log in information in a safe spot.

Note: Most insurance companies only require BCBA’s to have a CAQH profile.

Here is the link to the CAQH website:

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