Healthcare professionals are often confused between payer enrollment and medical credentialing. The entire process of credential verification and payer enrollment is intricate. With both enrollment and credentialing services being offered by Precision Hub, let’s look at what sets these two apart.

Payer Enrollment

The process of requesting enrollment in an insurance plan or panel is called payer enrollment. This process contains various application documents. Once these documents are submitted, medical credentials are then shared, along with supporting documents. Only when the credentials are verified is the practice granted acceptance.

Medical Credentialing

This is an exhaustive process. Background, identity, education, licensing, residency, and other checks are required to be performed. Physical and medical credentialing are generally used interchangeably. The entire process is extensive and can take up to 4 – 5 months.

The Differences Between Medical Credentialing and Payer Enrollment

Provider enrollment credentials are used when applying to join an insurance panel. Medical credentialing refers to a reservoir of data used to verify the status of a clinic and its members.

Payer Enrollment Types

The payer enrollment process varies. New hires go through a different process in comparison to staff members. The typical payer enrollment process consists of eight steps:

  • Enrollment request
  • Plan credentialing completion
  • Submission of license copies
  • Contract signing
  • Contract step unique to the contractor. This includes additional requirements that a provider has added to its enrollment plan.

Medical Credentialing Types

Some of the different credentialing types include:

  • Identity proof
  • Training and education certificates
  • Proof of military service (if applicable)
  • Professional license
  • State DPS, CDS certifications, and DEA registration

Board certification

  • Work and affiliation history

Criminal background disclosure reports

  • Sanctions disclosure
  • Health status
  • Professional references
  • Malpractice insurance
  • NPDB

These documents are required when a clinic files an application. From there, the CVO then verifies the information in the application before deciding on approving or rejecting the application.

See Also: 6 Steps To Streamline Physician Credentialing Process