What is credentialing?
Credentialing is a set of processes that healthcare facilities or health plans perform to make sure that the providers who would like to provide services for patients under these entities are who they say they are and are qualified to provide the services they want to provide. During this process, the providers’ background, licensing, history, and much more are checked and verified.
When a provider chooses to get a direct contract with an HMO, they need to provide the necessary documentation that the HMO requires from them and be ready to answer any questions regarding their background and qualifications to go through this credentialing process. Each HMO carries out its own credentialing process so unless the provider chooses to get their contracts through an IPA, they need to go through the credentialing process separately with each plan.
What is delegated credentialing?
When a healthcare entity like an insurance plan, delegates its credentialing privileges to another entity, such as a hospital or an IPA, this is called delegated credentialing. An entity with delegated credentialing privileges can carry out its own credentialing process internally, and go through an auditing process once a year to ensure that its process complies with the rules and regulations of the primary entity.
IPAs and hospitals can have delegated credentialing privileges for multiple plans at once. This means that once a provider submits their application to join the IPA and goes through the credentialing process, they can get their contracts with multiple different plans.
What is the average timeline for delegated credentialing?
The time it takes for a credentialing application to come to completion can vary depending on multiple factors such as the time of the month the application was first submitted.
The timeline starts as soon as the provider submits their credentialing application for the entity they are getting credentialed with. The entity that’s doing the delegated credentialing then starts reviewing their application. This review process can take up to a month. Once the delegated credentialing is complete, the entity submits all of the providers that have been credentialed to the relevant HMOs. It can take up to 3 months for the health plans’ provider data management department to process all of the requests and issue provider ID numbers. Once the provider has their health plan provider ID number, they can start providing services to patients within that plan’s coverage.
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