Welcome to Health Care POV | sign in | join
NP Practice Owners

How to Get Credentialed

Published January 21, 2009 7:42 AM by Aaron Hartle

If you plan on opening an independent practice, one of the most important things on your "to-do list" if you plan on billing insurance is to get credentialed. This is a long and arduous process taking from around 60 days to several months depending on the insurance company.

The sooner you can get started, the better off you will be. I'll walk you through what you'll need to become credentialed and how to get started.

What you need:

1. A business address: As soon as you have one, start the credentialing process, even if you will not be starting your practice right away.

2. Tax ID #: These are easily obtained from your local government web site.

3. NPI #: apply online at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

4. State license, DEA number, business license

5. CLIA waived certificate: If you plan on drawing labs or doing in-office tests. For information go to: www.cms.hhs.gov/CLIA/downloads/HowObtainCertificateofWaiver.pdf

6. Professional liability insurance: Generally $1 million / $3 million is required.

7. Education history, transcripts, and professional memberships and certifications.

8. Three or four good professional reference.

9. Go online to http://www.caqh.com/ to register to be credentialed with several different companies.

10. Call the credentialing departments of the rest of the insurance companies you wish to bill and get started. You can find the numbers on each of the insurance companies web sites.

Be patient, remember the processes takes weeks to months. As soon as a company sends you an application or contract, quickly fill it out and send it back. If you don't hear from insurance companies for awhile, call the credentialing office or provider relations number and follow up.

Good Luck!

13 comments

Can an Independent  RN bill health insurance companies for nursing service rendered?

What about for Medicare?

Kerry, HOME INFUSION - RN, ALL-In-One Healthcare solutions August 12, 2011 2:00 AM
Glendale CA

Looking to get credentialed and get billing help plus free software...contact billPDS.com and ask for Gary.   $150.00 for credentialing and a flat percentage rate for billing.  We have almost reached the end of the credentialing nightmare but just started out after my former employer ignored our CPA agreement which was based on my productivity.   My husband made the mistake of using Healthfusion as the EMR system that promised to "set you up with every insurance company except Medicare and Medicaid" for only $219.00 if we used the Obamacare mandatory EMR.  After a few weeks he called them to find out the status and found out "well, we usually set up established offices".    We have existed on co-pays, self-pays and moonlighting so far.  Our biller tells us that we finally got my medicaid number, not the Carolina Access, a few major private companies and almost on Medicare, Tricare.  It's a good thing I have a decent patient following because the overhead is astronomical.  You also need your facility insurance (building and accident), workman's comp as well as the malpractice.  I have a pretty decent business plan I'm willing to share if I can start getting NPs to stick up for each other and demand we work independently across the country.  I don't like having a 3rd party decide how much I am worth, especially if the patients would rather see me.  Medicaid on my own under Obamacare is going to give me 80% of 85% reimbursement for the same service so everything has to go through a physician that gets a substantial cut.  So much for the myth of equal pay for equal work.  I would also like to add that my NP association (left off so they cannot retaliate) has been no help at all.  Besides contacting me about elections they ignore me but current laws mandate I pay my dues in order to make a living.  At least my patients love me. :)  I wish I had found the checklist before plunging into this business but the business is mine so I'm building equity at the same time.  Taxes are a whole other issue we need to address as a group also.  For the first 3 months I was like a little duck, cool and calm on the surface and paddling like heck below the surface.  

send an inquiry to teej782@hotmail.com for a base business plan.  

Cheyanna, Primary Care - FNP-C, John P. Rosenick Family Medical Clinic March 25, 2011 7:06 PM
Sanford NC

My partner and I recently opened our own NP practice in North Carolina. Our patient population is approximately 70% BCBS. BCBS has refused to credential us as an independant practice. Has anyone found a way to become credentialed with BCBS?

Carolyn Davis, Pain Management March 8, 2011 9:22 PM
Mooresville NC

I am working for a CPNP that is opening her own pediatric practice in GA.  We are trying to get her credentialed with the insurance carriers but have hit some obstacles since she's a mid-level.  What if any workarounds are there to get her credentials with carriers that say they won't accept her?  For example, Blue has said that she has to work FT in the rendering doctors office.  Any advice????  Blue is a big one she needs in-network for!

Julianna , Medical Billing - President February 11, 2011 11:53 AM
Atlanta GA

Excellent step by step description of the process.

James Devaney, Psych/Mental Health - RN , PeaceHealth November 20, 2010 5:17 AM
Eugene OR

Medicare and Medicaid credentialing.

I currently have a medicare number that my current practice applied for me. I am thinking of leaving this practice and starting my own.

q1 Can I still use this number? If not,

q2. How do I go about reapplying for a new one? Or do I have to re apply.

My medicare number was applied for me by the billing company which charges exorbitant fees.

q3. Need a link to Medicare credentialling.

q4. Once credentialling is done, how do bill Medicare or Medicaid directly? Is there a web link you can advise.

Thank you

Mona

Mona Cheung, FNP January 13, 2010 12:09 AM
Plano TX

I am also in the process of writing a business plan for an independent practice.....for a mobile clinic. Does anyone have a example of one they have written...........you can just send the rough draft...leaving out your company info and corporate stuff......Thanks so much

Thelma, Family Practice - Nurse Practitioner February 17, 2009 11:17 AM

Well, I am not sure of a form that will let you credential with all three states.  You may be able to credential with one, then add your other locations later.  I am opening a second clinic, so all I have to do is add the new address, but I am not sure about different states.

Aaron

Aaron Hartle February 16, 2009 4:21 PM

Aaron,

I am looking to credential my company with Medicare in 3 states New Jersey, Pennsylvania and Delaware and I want to do all 3 at the same time. Is there an application that allows me to apply to all 3 states on one application form?

Thanks,

kay.

Kay , Healthcare - Clinical Serv. Mgr. February 6, 2009 2:40 PM
Philadelphia PA

Great step by step.  I would add that you may need to check on your malpractice insurance requirements.  Our collaborative physicians need to have the same level of coverage as we do.  If you do not need a collaborative doc then it doesnt matter.

Gretchen Moen January 26, 2009 12:24 PM

Aaron,

Excellent step-by-step on what to do. I would add, start with Medicare as that takes the longest it seems.  Also, if NPs are in states where collaboration is a fact of life, you will need to have this in place as well.  

Some states will also have a statewide credentialing form that can be used with all your local insurers. It will have you lots of time to keep a copy and print it out every time to need it. You'll then only need to sign and send.

Good luck to everyone starting on this journey.

Barbara Phillips, NP January 25, 2009 4:56 PM
www.NPBusiness.ORG

I am in the process of writing a business plan for an independent practice. Does anyone have a example of one they have written. Thanks

Karen Huddlestun, Family Practice - Family Nurse Practitioner, Dynamic Family Medicine January 21, 2009 7:32 PM
Casey IL

Great post Aaron!  That is so true, "That wait for credentialing"!  That will be helpful to readers who are just starting.

Joseph Marra, Family Health - Owner, Urgent Care Center January 21, 2009 12:55 PM
Altoona, Philipsburg PA

leave a comment



To prevent comment spam, please type the code you see below into the code field before submitting your comment. If you cannot read the numbers in the image, reload the page to generate a new one.

Captcha
Enter the security code below:
 

Search

About this Blog

Keep Me Updated