Credentialing & Enrolment

At Proactive, we expertly handle the full scope of the credentialing process, ensuring every step is managed with precision and efficiency. From submitting initial applications to handling ongoing updates, we take care of all the paperwork, verifications, and communication with insurance carriers and regulatory authorities.

This ensures your practice remains fully credentialed and compliant, allowing you to focus on what truly matters—delivering top-quality patient care. With our support, you can significantly reduce administrative burdens, avoid costly delays, and streamline your practice’s operations.

Credentialing is a critical process within the healthcare sector, safeguarding that medical professionals such as doctors, nurses, and allied health providers meet the necessary qualifications to provide safe, effective care. The credentialing process involves a thorough assessment of an individual’s education, training, certifications, licensure, and professional history. Often managed by specialized credentialing agencies, this process ensures providers uphold high standards and adhere to industry regulations. Below are some key components of the credentialing process:

Key Elements of Our Credentialing Services

Education and Training Verification

Our credentialing experts verify healthcare providers’ educational background, including their medical degrees, residency training, and any additional fellowships or certifications. This process ensures that providers have the appropriate qualifications to practice safely within their field.

Licensure Verification

We confirm the validity of a provider’s license by working directly with state medical boards or licensing authorities. This ensures that all healthcare providers meet the legal and professional requirements necessary to practice in their state.

Employment History and Professional References

Our team carefully examines a healthcare provider’s employment history, reviewing prior roles and clinical expertise. Additionally, we gather professional references from supervisors and colleagues to evaluate the provider’s performance, professionalism, and competence.

Malpractice History Review

We conduct a detailed review of any malpractice claims or legal actions involving a provider. This critical step helps to assess the provider’s risk profile and ensures that patient safety remains a top priority.

Board Certification Verification

If a provider claims board certification in a specialty, we verify their credentials with the appropriate certifying board. Board certification is an important indicator of a provider’s expertise and commitment to advanced knowledge in a specific area of medicine.

Ongoing Monitoring and Re-Credentialing

Credentialing isn’t a one-time event—it’s an ongoing process. We ensure that healthcare providers stay current with education, licensure, and professional standards through regular re-credentialing. This helps your practice maintain compliance and uphold the highest level of care.

Provider Enrollment Assistance

We guide healthcare providers through the enrollment process with insurance companies, Medicare, Medicaid, and other third-party payers. Our team manages the completion and submission of the necessary applications and documentation to ensure providers are approved for reimbursement.

Why Credentialing is Crucial

Credentialing plays a fundamental role in maintaining healthcare quality and protecting patients. By thoroughly vetting healthcare professionals, the credentialing process ensures that only qualified providers are allowed to practice. This step helps prevent fraudulent claims, ensures regulatory compliance, and reduces the risk of substandard care, safeguarding both providers and patients alike.

The Credentialing Timeline

The credentialing process can take anywhere from 1 to 4 months, but when not executed correctly, it can extend to a year. Once credentialing is successfully completed, the next step is contracting, which typically takes 15 to 45 days. The credentialing process involves numerous forms, supporting documents, and applications that must be submitted correctly, often varying by specialty.

Specialty-Specific Credentialing

Credentialing varies significantly by medical specialty, with each one having its own set of required procedures, documentation, and standards. As a result, our team tailors our approach to meet the unique needs of each specialty, ensuring compliance without unnecessary delays.

Our Full Suite of Credentialing Services Includes

EDI/ERA/EFT Setup

We can assist you in setting up your EDI/ERA/EFT setups with different insurance companies for electronic claims submissions, rejections, eligibility, payment information, denials, and electronic fund transfers.