Provider Onboarding -The Credentialing and Enrollment Process
Credentialing and Enrollment services can help your health plan:
- Improve the physician onboarding experience
- Maintain network accuracy
- Gain a single source of truth for all provider credentialing data.
“So before a provider can have a fully executed contract and gain access to members, they have to go through credentialing. So, generally the process entails providers submitting a request for participation, or alternatively a provider being recruited by the network department because they require certain things for their network adequacy needs – certain specialties. So that triggers negotiation of a contract. Once the terms are agreed upon, the provider will sign the contract, and then that’s what you have – it’s called a semi-executed contract. At that point, credentialing is triggered. So before, again, a contract can be fully executed, a provider must be credentialed, must go through the quality review, and the peer review committee organization has to make the determination of whether or not this provider meets their internal standards. Once a provider decision is made at the credentialing, that’s re-routed back to contracting… contract is fully executed, network is notified, the provider is enrolled. So immediately, the network and contracting departments can be impacted by any delays associated with credentialing.”
Anna Arutyunyan, VP of CVO Services