Insurance Credentialing & Contracting

 Before a provider can bill a health plan as in-network, two separate things usually have to happen. The payer must credential the provider by verifying professional qualifications and background, and the payer must contract with the provider or organization by establishing a participation agreement that sets the terms for reimbursement and provider responsibilities. Credentialing, contracting, and provider enrollment are related, but the terms are not interchangeable, and many payers require all of them before a provider is paid as a participating provider.

Helping Hands Credentialing supports individual healthcare professionals, group practices, therapy clinics, ABA organizations, behavioral health providers, and multidisciplinary healthcare organizations through both processes with commercial health plans, Medicaid managed care plans, Medicare Advantage plans, behavioral health networks, specialty networks, and other private health plan arrangements.

Our work is designed to reduce preventable inconsistencies between provider licenses, NPI records, tax documents, CAQH information, practice locations, professional histories, and payer applications, and to carry each application from the initial participation request through credentialing, contract execution, and the administrative steps required after approval.

Request a personalized credentialing and contracting proposal based on your specialty, service area, providers, and target payer networks.

Insurance credentialing is the process through which a health plan or payer reviews a provider’s professional qualifications and background before approving the provider for participation.

The payer may review information such as:

• Professional licenses and certifications 
• Education, training, and work history 
• Professional liability insurance 
• National Provider Identifier information 
• Taxonomy and specialty classifications 
• Practice locations and service areas 
• Ownership and organizational information 
• Disclosure and sanctions information 
• CAQH or payer-specific credentialing profiles 

Credentialing is related to provider enrollment and contracting, but the terms are not interchangeable. Credentialing evaluates qualifications. Contracting establishes the network participation agreement. Enrollment loads the provider or organization into the applicable payer or government-program systems.

Insurance contracting is the process of establishing a participation agreement between a healthcare provider or organization and a health plan.

The agreement may address:

• Participating provider responsibilities
• Covered products and plan lines
• Reimbursement methodology
• Claims and billing requirements
• Credentialing obligations
• Medical-necessity and authorization requirements
• Provider directory obligations
• Record maintenance and audit requirements
• Termination and renewal provisions
• Compliance with payer policies and manuals

Helping Hands provides administrative credentialing and contracting support. We do not provide legal advice or replace review by a qualified healthcare attorney when legal interpretation or negotiation of contract language is required.