Insurance Plans and Joining their Networks:
Contracting is the process by which you become legally engaged with an insurance plan so that you can offer services to their members as an in-network provider. The insurance plan will send you a contract which should include the terms of your agreement. This will include, but is not limited to, your obligations as a provider in their network, their obligations to you, the amount of time you have to file a claim and the amount time they have to pay a claim, the lines of business you will be participating in, the term of the contract’s length, how to terminate the contract and the structure of their reimbursement to you for the services you provide. Often the terms “contracting” and “credentialing” are used interchangeably, but they are in fact two separate processes. Some insurance plans will contract with you first and then credentialing you; others will credential you first and then contract with you. An insurance plan will issue you an “effective date”, which is the date you are recognized as an in-network provider. As of the effective date, you will be able to start to see an insurance plan’s members and will be reimbursed as an in-network provider. Any dates of service prior to the effective date will generally not be covered, unless these are paid at an out-of-network rate or there are other extenuating circumstances that you may be able to address in the contracting process. Please be aware that insurance plans have the right to close their networks to new providers and are not obligated to add a provider to their network.
Credentialing is the process by which an insurance plan verifies your education, licensures, insurance, work history, etc. are valid and up to date. CAQH Proview is a credentialing platform that most insurance plans use now. You will need to have a CAQH account set up and up to date. You can do that through Proview:
Setting up your CAQH account does take some time and you will need to upload documents to their platform. Insurance plans, by law, have 45 days to credential you. That time typically starts when they open your file, not when you submit your application or letter of interest. If there are any issues in the credentialing process, such as finding your information is not up to date or a gap in your work history, this “stops the clock” until those issues are resolved. A provider is typically re-credentialed with a plan every three years and must maintain current and accurate information in their CAQH profile while they are contracted with a plan and through the re-credentialing process.
Loading is often the step that is forgotten in the timeline. Once an insurance plan has credentialed and contracted with you, they need to load you into their system(s). Insurance plans can take up to 30 additional days to complete this step. It varies among the insurance plans as to whether they issue your effective date before or after they have completed loading you. If they issue an effective date prior to the completion of you being loaded, you can start to see their members, but you may need to wait to file claims until the loading process is completed. If the effective date is not issued until after you are loaded, the date will be further out, but you would not need to wait to file any claims at that point.
Are you already credentialed with an insurance plan with another group or entity? While an insurance plan still has the 45 days to credential you, the process should go faster. The insurance plan will still need to verify that the credentialing is in place, but at that point, they can move ahead with linking or affiliating you with your new entity. As a provider, you can be affiliated with as many entities as you would like, but you must make sure that the insurance plan has you affiliated with each of the entities in their system(s). If you are no longer practicing with a practice, it is important that they notify the plan and unaffiliate you from their practice.
This is a general overview and each insurance plan does have its own policies, procedures, paperwork and application processes. SWBHIPA does assist with the contracting and works with the health plans as they credentialing and load providers to make it go as smooth as possible.