Medical credentialing is a process used to evaluate the qualifications and practice history of a doctor to establish competency. This process includes a review of a doctor’s completed education, training, residency, and licenses. It also includes any certifications issued by a board in the doctor’s area of specialty. Hospitals, insurance providers, Medicare and Medicaid conduct medical credentialing to determine which physicians meet their requirements prior to permitting them to practice in their network. These entities continue to do so, on a regular basis as dictated by states, regulatory bodies and accrediting organizations. While this may seem like a simple, straight-forward process, each hospital and third-party agency requires their own specific type of medical credentialing processes, forms, rules and requirements. Therefore, it is imperative to know the specifics of each hospital or agency in order to save time, money, and headaches. Without specific knowledge of what is required or not completing the forms accurately credentialing could take months.
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§ When submitting the 855B form, the name of the practice must match exactly with the name submitted on the practice’s IRS letter, the National Provider Identifier (NPI) letter, and the practice checking account.
§ When you have multiple office locations, each of those addresses must be on file with each health plan. If you send in a claim with an office address that is not in the health plan’s billing system, the claim will either be denied or paid as out-of-network.
§ In most cases, only authorized or delegated officials may report changes to the practice’s Medicare enrollment record.
§ Once a physician’s Medicare number is issued, it must be used within a 12-month period or face deactivation. If deactivated, the 855I form will need to be resubmitted.