Stop Credentialing Denials: A 6-Step Submission Process for Home Health and Hospice Providers
Credentialing with insurance plans—also called joining a provider network or becoming paneled—is the process that enables healthcare providers and agencies to bill insurers for covered services.
Whether you are an independent practitioner or starting an agency, the credentialing process typically includes these six key steps:
1. Preparation and Core Credentials
Before contacting an insurance company, make sure your core professional profile is complete. Even one missing identifier can delay the process for months.
- National Provider Identifier (NPI): Obtain an individual NPI (Type 1) and, if you operate a business or agency, an organizational NPI (Type 2).
- Business Structure & Tax ID: Establish your legal business entity and obtain an Employer Identification Number (EIN) from the IRS.
- Licensure & Certifications: Collect active, unrestricted state licenses, DEA registrations (if needed), and proof of clinical certifications.
- Malpractice/Liability Insurance: Maintain a current Certificate of Insurance (COI) that meets payer minimum coverage requirements in your state.
2. Set Up and Maintain Your CAQH Profile www.caqh.org providers
The Council for Affordable Quality Healthcare (CAQH) is an online platform most commercial insurers use to review provider credentialing details.
- Create an Account: Sign up through the CAQH ProView portal.
- Enter Your Information: Include your education, employment history, specialties, disclosures, and practice locations.
- Upload Documents: Submit your license, CV, and malpractice face sheet.
- Attest: Electronically confirm that the information is accurate.
3. Payer Strategy and Market Analysis
Instead of applying to every panel, focus on insurers with the strongest market presence in your service area and the best fit for your target clients.
- Commercial Payers: Examples include Aetna, Blue Cross Blue Shield, Cigna, and UnitedHealthcare.
- Government/Public Programs: These include Medicare (through your local MAC) and your state Medicaid program or its Managed Care Organizations (MCOs).
4. Step 4: Submit the Letter of Intent (LOI) and Application
Once you know which panels you want to join, the formal process begins. This usually consists of two distinct phases: Credentialing (verifying who you are) and Contracting (negotiating the business agreement).
- The Letter of Intent (LOI): Many networks require an initial LOI or a "Pre-Application." This is your elevator pitch. Explain your specialty, your location, the specific demographics you serve (e.g., Medicaid, geriatrics, chronic disease management), and why your services are necessary to their network.
- The Formal Application: Once invited, complete their specific provider network application. This is where you will point them to your CAQH ID.
Network Adequacy Check: The insurer will determine whether it needs more providers in your specialty and geographic area.
- Closed Panels: If a panel is full, your application may be denied at first. You can often appeal by emphasizing services that set your practice apart, such as chronic disease programs or bilingual staff.
5. Credentialing Verification
If the payer accepts your request, it will retrieve your CAQH information and verify your background, including your education, work history, malpractice record, and state board status.
- Timeline: This step is often slow and typically takes 90 to 180 days for each insurance company.
- Follow-Up: Check in with your network manager or enrollment specialist every two to three weeks to confirm they are not waiting on additional documents.
6. Contracting and Effective Date
After you clear credentialing, the payer will issue a Provider Agreement (Contract).
- Review Fee Schedules: This document lists your reimbursement rates. Review it carefully to confirm the rates support your business.
- Sign and Return: Once both parties sign, the insurer will issue your official Effective Date and provider number.
- Do Not Bill Too Early: Do not see in-network patients or submit claims before your official effective date, or the claims will be denied.
If you are struggling to get contracts with private insurance companies or are unable to get on their panel of providers, you are not alone. At
Kenyon HomeCare Consulting, we understand the complexities of the process and how frustrating it can be. If you need additional assistance, contact
gkenyon@kenyonhcc.com or call 206 721 5091. We are here to help.
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