Question 1

What is the difference between Individual NPI vs Group NPI?

Accepted Answer

The CMS (Centers for Medicare and Medicaid Services) describes them like this.
 
Type 1: Healthcare providers who are individuals, including physicians, dentists, and all sole proprietors. An individual is eligible for only one NPI.
 
Type 2: Healthcare providers who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself into a group practice.
If you are an individual doctor or solo practitioner, you will need to start with a Type 1 NPI. Your individual NPI is akin to your social security number. It is a personal identifying number for you as an individual healthcare provider.
 
A Type 2 NPI is for group practices from large to small. Most group practices that supply superbills to their patients should have a Type 2 NPI. In some cases, even if you are the only healthcare provider in your practice it may be necessary to have a Type 2 NPI for your practice. For example, Florida Bluewill only accept superbills with a EIN if the EIN is tied to a Type 2 NPI in their out-of-network provider database.

Question 2

Where on the CMS- 1500 Form is the NPI used?

Accepted Answer

You will notice that there are spaces for both types of NPI on the form. Box 24J (Rendering Provider ID#) is the space where you enter the Type 1,or individual NPI, and Box 33A (Billing Provider NPI) is the space where you enter the Type 2, or group NPI.
https://static.wixstatic.com/media/undefined

Question 3

Why is this insurance panel closed?

Accepted Answer

Currently, many insurance panels are closed due to the amount of providers they currently have. There are not enough patients in the network area to allow a new provider on

Question 4

When will the panel open back up?

Accepted Answer

The majority of companies will ask that you try again in 6 months.

Question 5

Can a denied panel access be appealed?

Accepted Answer

Yes. It is known that if you have a unique specialty and or speak more than one language, many insurance companies will be willing to accept your appeal and allow you on the panel.

Question 6

What is CAQH?

Accepted Answer

The CAQH is an important aspect of all medical credentialing and should be completely set up in order to even begin the credentialing process. In order to get a CAQH ID so that one can complete a profile, one must contact an insurance company for that number. We recommend doing this with Humana or Aetna. Once you have received your ID, you will go to www.caqh.org and complete your profile. This profile is essentially your application for a lot of insurance companies. You will want to make sure that all of the information within the profile is accurate. When you go to apply to the many different insurance companies, there will be a place on you initial request to join the company that you will put your CAQH number.

Question 7

How long does Credentialing take?

Accepted Answer

Almost every person we work with wants to know how fast they can get on insurance panels. This depends mainly on the panel but overall it is going to take 4-5 months to be fully credentialed and ready to accept patients that use that insurance. This might surprise you, as many falsely believe that the credentialing process only takes an inkling of time. In reality, the process is made up of a few steps that each take a lot of time and effort. First, for example, one has to fill out a separate application for every single company they hope to get credentialed with. Then, comes the time to actually submit these applications and ensure each company received said application. Then, it’s time to follow up.

Question 8

What documents are required by the insurance companies?

Accepted Answer

There are several documents that all insurance companies will ask for when processing your credentialing application. They will require a resume in month/year format and an explanation if you have a gap in your work history. They will want a copy of your current liability insurance, current license that has your expiration date on it, and a diploma from your highest earned degree.

Question 9

What is demographic update?

Accepted Answer

Updating your profile by changing demographic information.

Question 10

Who gets credentialed?

Accepted Answer

Practitioners who are independently responsible for patient care by virtue of their license must be credentialed.
 
Credentialed providers include:
• Physicians
• Dentists
• Podiatrists
• Ophthalmologist
• Advanced Practice Nurses
• Physician Assistants

Question 11

What is Credentialing?

Accepted Answer

Credentialing is a term that usually encompasses two separate processes: credentialing and privileging.
• Credentialing: Primary source verification of a health care practitioner’s education, training, work experience, license, etc.
• Privileging: Granting approval for an individual to perform a specific procedure or specific set of procedures based on documented competence in the specialty in which privileges are requested.

Question 12

What is Primary Source Verification (PSV)?

Accepted Answer

PSV is the process of verifying credentials directly with the source. For example, a credentialing office cannot accept a copy of a medical school degree as evidence that the physician graduated from medical school. The school must be contacted directly to verify the physician’s attendance and graduation.
 
• PSV is required so that hospitals and credentialing offices do not receive fraudulent documents from applicants or other non-primary sources.
• A credentialing office cannot accept any verification that comes through a third party rather than the primary source.
• PSV is a requirement by accrediting bodies as well as the cornerstone of a good credentialing process.

Consulting®

Quality Of Life

Collaborating with Quality

faq