What “credentialed” means and why nothing pays before the effective date.

Summary

What does credentialed mean?

Credentialing, enrollment and the effective date are three separate steps with each payer. Being credentialed means the payer has checked a provider's qualifications. It does not mean claims will be paid. Claims to that payer pay in-network from the effective date the payer sets in writing.

Owners say “credentialed” when they mean “we can bill now.” Payers use the word for one step inside a longer file.

What each step is.

Credentialing is the payer checking a provider's licenses and qualifications. Payer enrollment is the payer registering that provider, or the practice itself, so claims can be paid in-network. The effective date is the day the payer starts paying those claims.

A separate application goes to each payer for each provider.^A A provider can be fully enrolled with Medicare and still be out-of-network with every commercial plan nearby. Medicare enrolls through PECOS, its own system. The commercial plans read the CAQH profile.

The practice has a file too.

A payer enrolls more than people. The practice itself can need its own application with each payer, apart from the provider's, and a provider joining an existing group has to be tied to that group in the payer's records. That is why we price the two separately: $450 for an organization application and $350 for each practitioner application. For a solo practice we file and charge one application per payer, at $450.

Where a payer allows it, one contract covering every provider in the practice gives the practice more weight with that payer than a string of individual contracts.^A We ask each payer whether it allows one before we file.

The date that matters.

A claim for a visit before the effective date may never be paid. A phone call saying the file looks fine is not an effective date. Until the payer puts the date in writing, we treat it as unset, and the status record says so.

Will a payer reach back and cover visits seen while the file was still open? Medicare allows a short window of retrospective billing, set by regulation, when circumstances kept a physician or practitioner from enrolling sooner. Commercial plans and Medicaid decide case by case, in their own letters. We do not plan a practice's cash around either.

Why the gap stays hidden.

The provider believes they are in network, the front desk books the patient, the claim goes out, and the first sign of a problem is the denial.^C

In an older MGMA Stat poll of 425 medical groups, 54% said credentialing-related denials were rising.^B Each of those denials says the same thing in payer language. On the date of service, this provider was not enrolled with this payer.

Waiting without turning patients away.

Timing is the part the practice does not control. Commercial plans publish a month to two months or more for credentialing, often plus contract loading, and Medicaid varies by state.^A Two arrangements can help while the files are open. Neither one replaces enrollment.

A single-case agreement can cover one patient while a provider's credentialing is pending. The payer decides whether to grant it, usually when its network cannot serve that patient or when care is already under way. It does not put the provider on the panel.^D

Medicare's incident-to rule lets some visits by a provider who is not yet enrolled be billed under a supervising physician who is. The physician has to supervise on site, and the patient's plan of care has to be established already. Commercial payers set their own limits on it.^E

What to ask whoever is doing this work.

Whether enrollment sits with your office manager, a vendor or us, a few questions show where the practice stands. Which payers have an application in, and for which providers? Which of them has set an effective date, and where is it written down? Who follows up with a payer that has gone quiet, and on what day?

Our answer is the status record. It lists each payer, its status, the next action and the effective date once a payer commits to one. It shows you which payer is holding things up. When the work is done, the enrollment file stays with the practice. If we also run your billing, the claims go out under each date as it lands, and we follow each one to a payment or written payer decision.