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How to Smoothly Accomplish Medicaid Provider Credentialing

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Physician checking data for applying for provider credentialing

What is the Medicaid program?

Medicaid is a jointly funded state and federal healthcare program that provides care to low-income individuals. Where Medicare is entirely a federal program, Medicaid, by contrast, is wholly administered by each of the fifty states within their borders.

The Centers for Medicare and Medicaid Services (CMS) provides oversight while states administer the Medicaid program. Additionally, CMS issues federal regulations and sub-regulatory guidelines that states must adhere to in implementing their Medicare program.

The CMS has promulgated requirements for Medicaid Provider enrollment. Credentialing standards are set by the National Committee on Quality Assurance (NCQA) and CMS. States may also have additional regulations for providers to participate in their Medicaid program. 

Requirements to obtain Medicaid Provider Credentialing

To get credentialed in Medicaid, a provider has to fulfill requirements relating to education, training, licenses and work history

(i) Training and education details

  • Practitioner degree, post-graduate education/ training
  • Other professional education/training
  • Residency program in the designated specialty

(ii) Licenses and certification

  • Current license/certification in the state(s) in which the provider will be practicing
  • National Provider Identification (NPI) number
  • Active Drug Enforcement Agency (DEA) number

(iii) Work history

  • Five-year work history (gaps longer than six months to be explained).
  • W-9 form
  • Hospital staff privilege

(iv) Other

  • Malpractice history
  • Other Credentialing requirements such as AMA profile or criminal history review as required by Credentialing Authorities

Application Process

The next step is to complete a Council for Affordable Quality Healthcare (CAQH) ProView application.This is a fast and easy way to submit credentialing information securely. Furthermore, information can be entered just once and it becomes available to multiple health insurers.

In addition, some states may require the provider to fill out their own application with appropriate documentation. States may give the option of filling out their application online, via secure Email, or even offline through Post.

If the provider has a CAQH Provider ID number and is registered with CAQH ProView, the account must be checked to ensure it is up to date and complete. Finally, the provider will be notified when the application is complete. CAQH will also send a quarterly reminder to review and update information.

Providers are mandated to get themselves re-credentialed every five years for continued participation in the Medicaid program as per the Affordable Care Act. 

Bristol Healthcare can help you get credentialed

Finding all these procedures burdensome and time-consuming? Are you worried about the numerous and complicated information and documentation to be submitted?  Bristol Healthcare is here for you. We will take care of your credentialing worries. Whether credentialing, revalidation or keeping your information current with Medicaid, our team of experts will serve you with dedication.

Bristol Healthcare Services delivers complete medical coding and billing solutions using advanced technology and experienced staff. Certified and trained billers will take of your credentialing with Medicaid from whichever state you plan to serve. The team will guide you regarding the specific sub-regulations of your state, so your credentialing process moves without a hitch.

Provider Credentialing is the beginning of the healthcare revenue cycle and Bristol Healthcare is focused on ensuring improved collections for its clients. Additionally, our services help you reduce your operational and administrative costs. Further, our two-decade-long experience has helped us evolve processes that enable us to have fast turnaround times. Error-free work ensures quick reimbursement.

Allow us to serve you and take your practice to the next level!

Talk to an expert today!

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