Medical Credentialing Services

Medical Credentialing Services

medicare enrollment

You found this page perhaps because you are looking and searching about medical credentialing services. This post is about what this credentialing process can really do for your practice and why you must be careful in choosing the right people to help you.

Most of my physicians who just got out of medical school and want to start a practice or join a group, they want to join an insurance network to become a participating provider.

Now, what you will need a medical credentialing services consultant who can help you streamline the process and make it easier for you. As you might know, insurance contracting and credentialing is a very tedious work. You don’t want to go through that headache.

Medical Credentialing Services Provider

What you need to look for:

  1. They must have an extensive knowledge, experience and expertise on insurance contracting, negotiation and credentialing process;
  2.  Must be Familiar with the following:
    1. CAQH Council for Affordable Quality Healthcare (most Medical Credentialing Services company are familiar with CAQH)
    2. Medicare Enrollment Guidelines – PECOS or Paper Applications (Forms, Compliance and all related requirements for credentialing/enrollment)
    3. Liability Insurance Coverage (Professional/Individual and Facility/Group)
    4. National Provider Identification Guidelines (Individual and Organization)
    5. Different Insurance Payers’ Products (some physicians may join only the PPO part of the contract but not the HMO)
    6. Fee Schedule Analysis (I always tell my physician – “don’t sign the contract if you don’t agree with the fee schedule being offered to you by the payer”). Always compare your fees to Medicare’s fees where you can find them from your local Medicare’s website. The truth is because most of the time unfortunately, fee schedule are revealed to you based on the contract. If the physician don’t sign the contract, then there will be no contract done. An effective medical credentialing services provider is then able to negotiate the fees.
  3. Must be resourceful and knows how to handle communication with the Provider Services especially with the Contract Representative in the Area
  4. Submit to a weekly update on the status of the credentialing process
medical credentialing services

medical credentialing services

What you need to be familiar before you hire your Medical Credentialing Services Company:

Medicare Provider Enrollment:

  • You can submit through PECOS (Provider Enrollment, Chain, and Ownership System (PECOS)) ;
  • Or Submit Paper Application Forms;CMS-855B – Clinics/Group Practices and Certain Other Suppliers
    Clinics and group practices can apply for enrollment in the Medicare program or make a change to their existing enrollment information using the CMS-855B. Complete this application if you are an organization/group that plans to bill Medicare and you are:
    A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, and portal x-ray suppliers).
    A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.

    CMS-855I – Physicians and Non-Physician Practitioners
    Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855I. Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
    An individual practitioner who will provide services in a private practice.
    An individual practitioner who will provide services in a group setting.
    Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction.
    Currently enrolled in Medicare and need to make changes to your existing enrollment information.
    An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you’re the sole owner.

    CMS-855O – Ordering and Referring Physicians and Non-Physician Practitioners
    Physician and non-physician practitioners can apply to register for the sole purpose of ordering and referring items and/or services to Medicare beneficiaries or make a change in their registration using the CMS-855O. These physicians and non-physician practitioners do not and will not send claims to a Medicare Administrative Contractor for the services they furnish for reimbursement.

    CMS-855R – Reassignment of Medicare Benefits
    Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits. Reassigning your Medicare benefits allows an eligible organization/group to submit claims and receive payment for Medicare Part B services that you have provided as a member of the organization/group. Such an eligible organization/group may be an individual, a clinic/group practice, or other health care organization. A separate CMS-855R must be submitted for each organization/group where a reassignment is being established or terminated.
    Please note: Physician Assistants and Sole Owners do not complete the CMS-855R application for reassignment because the information is reported on the CMS-855I application.

    CMS-588 – Authorization Agreement for Electronic Funds Transfer (EFT)
    This form is used to have your Medicare payments deposited directly into your bank account. It eliminates paperwork and saves time by reducing routine banking.
    Included copy of voided check or bank letterhead

    CMS-460 – Medicare Participating Physician or Supplier Agreement (CMS-460)

You need an TAX ID number of which I assumed you have one. And you need an NPI for Individual Rendering Provider (this NPI appears on the claim forms when you submit claims) and another NPI for your Practice, Organization or your group.


medical credentialing services





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Author: Pinky Maniri

Ms. Pinky, as she is fondly called - is a Reputable Professional Consultant and Expert in Practice Administration, Medical Billing, Coding, Health Information Technology, Insurance Credentialing and Compliance for Physician Offices. Well-educated with a Degree in Computer Systems Engineering and a background in Clinical Nursing and Small Business Management. Her professional mission is to make sure her clients/physicians maximize reimbursement while they remain compliant with the current rules, changes, guidelines and policies. Read More About Ms. Pinky here and See what Other's say about her Expertise Testimonials

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