Medical Credentialing Services

Turnaround time varies between insurance carriers. Major carriers generally take between 90 to 120 days to complete the process. Smaller carriers and insurance plans may take longer.

Upon submitting a participation request to a commercial carrier, providers need to undergo two processes. The first of these is credentialing, where the carrier verifies all provided credentials and presents them to their committee for approval. Once providers are approved by the credentialing committee, they are then directed towards the contracting process wherein their participation is approved, and they are given their effective date.

Commercial carriers do not allow for retroactive billing, meaning providers will only be compensated for claims submitted after they are listed as an in-network provider in the carrier claims system. Out of network billing results in much larger bills for patients, who may be responsible for the entire bill on their own.

Enrollment in Medicare typically takes between 60 to 90 days to complete, though this varies between states. The effective date for Medicare is set as the date the application is received, allowing for providers to retroactively bill for any encounters that occur between application and approval. There is also a 30-day grace period, enabling providers to bill for service provided up to 30 days prior to their effective date.

Turnaround time is longer for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers. In addition to the close scrutiny that every application is subjected to, suppliers are also required to participate in a site visit as part of the application process. A site inspector is responsible for ensuring the office is located at the address included on the application, as well as hours of operation, where inventory is stored, and other important elements of being a DMEPOS supplier.

CureMD cannot make the process any quicker, but we do, however, efficiently and effectively manage the entire application process, beginning with initial credentialing applications and carrying through to follow-ups with carriers. Our experts are well-versed in the entire process, saving time that might otherwise have been wasted by providers attempting to perform the process themselves and making mistakes along the way.

Yes, it is necessary for providers to have a place of service before they begin the medical credentialing and contracting process. A home address cannot be used as a clinic address, either permanently or temporarily. A home address can, however, be used as an address for billing or correspondence, but only if a physical address for the practice is also provided. If office space is still under construction, the address can still be used. The application can be sent up to 30 days prior to the location’s official opening, and most commercial carriers also offer the same guideline.

Revalidation of Medicare enrollment is required every five years, but DMEPOS suppliers must revalidate every three years. Individual providers can either complete the CMS855I paper application or use Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) to complete the revalidation online.

Providers must respond to their Medicare carrier within 60 days of receiving their revalidation letter. It is important to respond promptly, or billing privileges may be terminated.

For groups or suppliers, the CMS855B application must be completed. If an electronic funds transfer was not previously set up for the group record, one needs to be created for the revalidation process.

The CMS855I application is used for individual provider enrollment in Medicare. It can be used by both physicians and non-physicians. Other necessary documentation varies between provider types.

Providers may also need to submit the CMS460 form to elect for participation in Medicare, without this form provider may be enrolled as nonparticipating providers. Nonparticipating providers will receive less reimbursement from Medicare, though they are also entitled to pursue more reimbursement directly from patients—up to 115% of the Medicare rate.

For providers enrolling under an existing group practice, the CMS855R form must be submitted. This form reassigns the provider’s financial payments to the business that performs the services.

The CMS588 form is needed for both individual and group practices, in order to set up electronic funds transfers (EFT) to receive Medicare payments. Medicare does not issue paper checks; reimbursement is only dispensed via EFT.

Summary of applications:

• Solo practitioner forming a new business entity: CMS855I, CMS460, and CMS588
• New provider joining an existing group: if already enrolled with the state intermediary: form CMS855R; if not enrolled with the state intermediary: forms CMS855I and CMS855R
• Form CMS460 may be required for new enrollment depending upon the status of the group/supplier