Provider credentialing manual

Healthcare contracting for specific lines of business discussed in this manual occurs after our credentialing process is complete. Once contracts are signed by the provider and counter-signed by us, the newly credentialed and contracted physician or other provider can then render medical services to our members and submit claims for payment. If the new physician or other provider is joining a contracted group practice, there may not be a need to sign an individual contract; however, we still require that all physicians and other providers be credentialed first.

Need a copy of your provider contract? Physicians or other providers enter into an agreement with us by signing our Provider Agreement, which serves as the contract for us and our affiliates. Our Provider Agreement contains the standard terms that pertain to all plans and products. For contracting questions, contact Physician and Provider Relations at , option 4. We want to ensure that members are appropriately transitioned whenever a physician or other provider contract is terminated.

To ensure continuity of care, the member must be notified and given the opportunity to transfer care to another physician or other provider - prior to the termination date. This process applies to all plans and whenever a physician or other provider of any specialty terminates our contract.

Note: Physicians or other providers are contractually required to provide us with a termination notice as set forth in their contract. If your organization is contracted with Premera, most practitioners must be credentialed, with the exception of hospital-based practitioners.

Learn more about which practitioners need to be credentialed by viewing our credentialing matrix, located as a separate PDF accompanying this document, and in our online credentialing manual, located in the password-protected section of our provider website.

Confidentiality of member information is paramount to us. All our employees sign a confidentiality statement to that effect. State and federal regulations protect privacy. Provisions for the protection of an individual's health and financial information protected personal information [PPI] are included in:. Try Smartsheet for free, today. In This Article. What Is Provider Credentialing in Healthcare? See how Smartsheet can help you be more effective.

Every health insurance company checks the credentials of a physician before it includes the doctor as an in-network provider. Paperless Credentialing: This term refers to software that expedites the credentialing process, decreasing or eliminating the need for paper forms.

Medical sales rep credentialing: Also known as vendor credentialing , this refers to healthcare organizations checking on and monitoring the background and training of sales reps and other vendors who may want or need access to the facilities. Credentialing is also used in non-medical contexts, including the following: Personnel Credentialing: This is when an organization assigns credentials to its employees or vendors.

Political Credentialing: This term refers to political parties assigning credentials to delegates for party conventions. How Does Provider Credentialing Work? The Primary Phases of Provider Credentialing The three primary phases of provider credentialing are as follows: 1.

Gather Information A healthcare facility or health insurance plan asks the provider for information on his or her background, licenses, education, etc. The provider may submit the information in a questionnaire through email or through software.

In some cases, the healthcare facility or insurance company works with a third-party company — called a credentials verification organization CVO — that works with the provider to gather and verify information. Organizations often hire CVOs to allow for more efficient credentialing. Check the Information In many cases, the facility or insurance company will do the background work. In other cases, the facility or insurance company may use credentialing software to continuously check information that licensing agencies and other entities make available online.

The CVO may also run verification checks. Many healthcare organizations use collaboration and work management platforms to help them organize and record provider information and get automatic updates when certain credentials expire or need to be re-checked. In all cases, the checks include monitoring reports about medical incidents, malpractice claims, or other information that could raise questions about whether to credential or re-credential the provider.

Award the Provider with Credentials After the organization verifies all required credentials and finds no negative issues, the healthcare facility awards credentials to the provider. After the health insurance company completes a similar process, it can decide to approve the provider as an in-network provider. That is, the insurance company will pay the provider for treating patients who have its insurance. Common Information Requested to Credential Healthcare Professionals There is some variance in the information required of healthcare providers by different healthcare facilities and insurance companies.

The oldest applications are processed first once all necessary information is received. Sending multiple emails requesting a status delays our response time. Use prism for requests and status updates We recently launched prism , where you can more quickly and easily request credentialing and changes. We have several different networks designed to meet various consumer needs.

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