Scribd
Upload
64 views4 pages

Provider Credentialing Training Manual Complete

The Provider Credentialing Training Manual serves as a comprehensive guide for medical billing professionals and credentialing specialists, detailing essential workflows, compliance guidelines, and payer-specific rules for U.S. healthcare reimbursement. It covers various aspects of credentialing, including the types of providers, National Provider Identifier (NPI) requirements, and enrollment processes for Medicare, Medicaid, and commercial payers. The manual emphasizes the importance of maintaining accurate records and compliance to avoid common denials and ensure efficient billing practices.

Uploaded by

medbillservicesllc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
64 views4 pages

Provider Credentialing Training Manual Complete

The Provider Credentialing Training Manual serves as a comprehensive guide for medical billing professionals and credentialing specialists, detailing essential workflows, compliance guidelines, and payer-specific rules for U.S. healthcare reimbursement. It covers various aspects of credentialing, including the types of providers, National Provider Identifier (NPI) requirements, and enrollment processes for Medicare, Medicaid, and commercial payers. The manual emphasizes the importance of maintaining accurate records and compliance to avoid common denials and ensure efficient billing practices.

Uploaded by

medbillservicesllc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Provider Credentialing Training Manual – Complete &

Detailed Notes
This manual is designed for medical billing professionals, credentialing specialists, and RCM teams. It provides
end-to-end credentialing workflows, compliance guidance, payer-specific rules, and best practices used in U.S.
healthcare reimbursement.
1. Credentialing Fundamentals
- Credentialing verifies a provider’s education, training, licensure, and professional history.

- It is a prerequisite for submitting claims and receiving reimbursement.

- Credentialing differs from enrollment; credentialing validates qualifications, enrollment activates billing.

2. Provider & Entity Types


- Individual Providers: MD, DO, NP, PA, LCSW, LPC, PT, OT.

- Group Practices: PLLC, LLC, PC.

- Facilities: Hospitals, ASCs, Diagnostic Labs.

- Billing Entities: Type 2 NPI organizations.

3. National Provider Identifier (NPI)


- Type 1 NPI is assigned to individual providers.

- Type 2 NPI is assigned to organizations or groups.

- NPI data must match credentialing and claims data exactly.

4. CAQH ProView – Step-by-Step


- Create CAQH account and obtain CAQH ID.

- Enter education, training, practice locations, and insurance.

- Upload all supporting documents.

- Authorize payers and attest every 120 days.

5. Medicare Credentialing – PECOS


- CMS-855I: Individual enrollment.

- CMS-855B: Group enrollment.

- CMS-855R: Reassignment of benefits.

- CMS-588: Electronic Funds Transfer.

- Revalidation is required every 5 years.

6. Medicaid Credentialing
- State-specific enrollment requirements.

- May require fingerprinting and site visits.

- Revalidation timelines vary by state.


7. Commercial Payer Enrollment
- Common payers: Aetna, UHC, Cigna, BCBS, Humana.

- Enrollment via CAQH or payer portals.

- Credentialing committee review is required.

8. Taxonomy & Practice Address Rules


- Taxonomy must match provider specialty.

- Practice address must align with payer records.

- Incorrect taxonomy causes claim rejections.

9. Credentialing Timelines & Follow-ups


- Medicare: 30–90 days.

- Commercial: 60–180 days.

- Follow up every 14–21 days.

10. Common Denials Related to Credentialing


- Provider not enrolled.

- Incorrect billing NPI.

- Inactive or expired credentialing.

11. Retroactive Billing Rules


- Medicare allows limited retroactive billing.

- Commercial payer policies vary.

- Claims submitted before approval may be denied.

12. Revalidation & Ongoing Maintenance


- Track license and insurance expirations.

- Maintain credentialing calendars.

- Keep documentation audit-ready.

13. Delegated Credentialing


- Organizations credential internally.

- Requires payer approval and audits.

- Strict compliance standards apply.


14. Compliance & Audit Readiness
- Maintain provider files for audits.

- Ensure data consistency across systems.

- Non-compliance leads to payment holds or termination.

15. Best Practices for Credentialing Teams


- Use credentialing trackers.

- Centralize documentation.

- Communicate approvals to billing teams.

You might also like