CMS credentialing is necessary for you to get paid as a healthcare provider or practice. This step makes you eligible to receive reimbursement for Medicare and Medicaid bills.
However, it may not be a cakewalk to fulfill needed criteria and complete a process to get credentialed.
Every year, more and more people enroll themselves under Medicare and Medicaid policies, and more than half of them are above the age of 65. As this number rises, the need for CMS credentialing also increases. On the other hand, if you are not credentialed, the chances of delayed payment and revenue losses pile up.
Building an efficient revenue cycle management is possible only when you ensure that you have a valid license to treat patients. Let’s understand what credentialing is, its process, and what’s holding you back.
Why You Need CMS Credentialing as a Healthcare Provider
If you render medical services to Medicare patients, you must first get an authorization. If you treat Medicare patients without this authorization, you will not receive reimbursement for the same.
But what does it mean to be authorized?
It simply means completing the process of CMS credentialing. The framework requires you to follow a step-by-step sequence and verify yourself as an eligible healthcare provider.
Being eligible directly denotes that you meet all the required federal compliance standards and get a license to treat Medicare and Medicaid patients.
You, as a physician, need credentialing, but it is also very important for nurse practitioners, physician assistants, occupational therapists, clinics, DMEPOS suppliers, and more.
Check boxes You Need to Complete Your Credentialing Process
No. 1
You must hold an active or valid state license that approves credentialing and billing. The CMS also reviews aspects like your sanctions, exclusions, and license history.
No. 2
CMS checks your qualification, training, and board certification via credentialing entities like Medicare Administrative Contractors and PECOS. This verification decides whether you can receive revenue for Medicare and Medicaid patients or not.
No. 3
You must ensure that you have malpractice insurance. This will confirm that you have coverage in case any malpractice happens. This is important for commercial insurance credentialing and CMS enrollment, but it is not a strict requirement.
No. 4
CMS also verifies your NPDB report, which ensures that there are no malpractice claims or disciplinary actions against you.
No. 5
If you have any business ownerships, like groups or entities, then you must disclose this as well.
Credentialing Process - From the First Step to the Last
By now, you may be thinking that credentialing is something that regulates you as a healthcare provider and imposes various requirements. But it makes sure that you get paid, protects your interests and authenticates your eligibility.
Here’s a step-by-step process for CMS credentialing:
The First Step Is NPI
The step involves both the creation and verification of NPI.
What is NPI? It’s the National Provider Identifier, a unique 10-digit number that acts as your digital identity and is used for medical billing. Whether you cater to Medicaid, Medicare, or other insurance payers, NPI is essential for the billing process.
You need a valid NPI if you want to get authorized by CMS and bill Medicare. Your NPI holds all your information, such as your location, data related to your practice, insurance information, and more.
A valid and updated NPI is crucial if you don’t want your Medicare applications to get delayed or rejected. The process of acquiring an NPI includes visiting the official website, entering the required credentials correctly, and enrolling yourself for the NPI.
The Second Step Is Documentation
In this step, you are supposed to gather all your documents (related to medical qualification and field) to file your CMS application. Your documents are needed, as they support your claim of being a professional with valid qualifications. You are supposed to ensure that there are no mistakes or missing details.
Then you have to file the CMS-855 for the PECOS application accurately. If you want to get first-time approval, then you must avoid making mistakes during this step.
Collecting all your documents and organizing them will help you file your application form at once and avoid unnecessary mistakes.
The Third Step Is Choosing the Form – CMS-855
The type of form you choose will decide if credentialing will help you earn revenue. There are different types of CMS-855 for different healthcare providers. You must pick the one that aligns with your administrative needs as healthcare providers.
- Individual Healthcare Practitioner – CMS855I
- Group Practices and Organizations—CMS855B
- DMEPOS – CMS855S
It is also important for you to stay current with the process and use the latest version of the form available on the website.
The Fourth Step Is the Submission of the Application
This is the step where we actually do the enrollment process. It involves submitting your application on the PECOS website/portal (Provider Enrollment, Chain, and Ownership System).
Make sure to submit a digital form and not rely on the manual CMS-855 form, as it ensures that the process is accurate. You get real-time visibility into form submission so that you can track the ongoing status of your application.
- To complete this step, you must first go to the website/portal and log in with your credentials.
- Then go through the application steps one by one while ensuring you are filing everything correctly.
- Then upload your documents, like your license, NPI, and other insurance-related documents.
- After that, check it before submission and save/print the submission confirmation.
The Fifth Step Is Answering Corrections in Your CMS Form
After you have submitted the application, the CMS may need corrections or some other data in your form. Answering all these queries ensures that your application is moving step by step consistently.
The only catch is that if you don’t respond to CMS alterations within the stipulated time frame, you will have to begin the entire process again.
Always answer the requested clarifications, make corrections, and resubmit the application before it gets dismissed.
The Sixth Step Is Tracking Your Application and Maintaining It After Approval
CMS credentialing is more than just getting authorized for receiving Medicare and Medicaid revenue. After you have your approval, you must keep up with your application and maintain your records. This means that you must revalidate your documents and update the information to keep your authorization valid.
You can also set reminders to track when your revalidation cycle ends and update it before you face any revenue interruptions.
Major Reasons Behind Credentialing Delays
You may think that the process is simple when you have met certain criteria and track it to keep it updated. But there are common mistakes that healthcare providers make that hamper your credentialing process.
- Following a manual process increases the chances of delays and prevents you from achieving adequate revenue.
- There is also a chance of errors, so if you don’t double-check every detail before finalizing it, you will not get your NPI.
- Missing out on answering corrections given by NPDB; if this happens, your credentialing process suffers.
- Not tracking your application after submission. If your authorization gets invalid, you face the possibility of denials and revenue losses.
Final Thoughts
CMS credentialing is vital for healthcare providers and practices that treat Medicare and Medicaid patients. Without it, you miss an opportunity to improve your revenue cycle management, streamline operations, and boost the bottom line.
If you want to go through the process smoothly and not face the common mistakes that cause denials, then getting it done by professionals is the ideal option. Eminence RCM is a medical billing and coding company that offers credentialing services to healthcare providers and practices across the US.
We know that it’s difficult to handle patients and the administrative process alone. That's why we are here to take away your stress and help you achieve credentialing, revenue maximization, and comprehensive profitability.
So, partner with Eminence RCM and experience smooth credentialing and medical billing today!
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