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Essential steps for smooth Medicare provider credentialing

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Medicare provider credentialing is the process of approving a physician, supplier, or other medical professionals as part of the Medicare supply chain. A credentialed Medicare provider renders medical services to Medicare beneficiaries. 

To get credentialed with Medicare, a provider must fulfill specific criteria to go through the enrolment process. Essential steps in Medicare credentialing are:

(I) Medicare has delineated the following broad stages for being considered in-network for Medicare patients:

  1. 1) Obtaining a National Provider Identifier (NPI) by applying on the National Plan and Provider Enumeration System Website.
  2. 2) Completing a Medicare provider enrollment application through the Provider Enrollment, Chain and Ownership System (PECOS) if you are applying online. Applications can also be sent on paper through US postal mail.
  3. 3) Selecting the taxonomy code.

(II) The following points need to be taken care of before starting the credentialing process

  1. a) The provider must have a primary place of service in operation
  2. b) Banking information to setup EFT payment for Medicare reimbursement
  3. c) Personal details of every individual having an ownership stake in the practice to be available
  4. d) Supporting documents vary with the type of provider enrolling
  5. e) Citizenship documents are required for providers born outside the US.
  6. f) ECFMG certificate is required for the provider’s education outside the US.
  7. g) Sign the application forms correctly in every signature location

(III) Medicare will require a provider to meet all of the credentialing and licensing requirements of their field. As such, the following documentation would be required to be submitted as part of the application process:

  • Tax records
  • Proof of malpractice insurance
  • Practitioner licenses
  • Diplomas
  • Board certifications
  • Federal and state CDS certificates
  • Current CV using a month and year format
  • Proof of identification

Medicare credentialing can take up to 60-90 days. However, a provider can bill 30 days prior to the date Medicare receives the application (effective date).

(IV) To maintain billing privileges, Medicare requires providers to undergo revalidation every five years. As before, the process can be done online, or papers can be sent by post.

(V) Medicare also requires providers to inform them if there are changes in the following enrolment information within 30 days

(i) a change in ownership

(ii) an adverse legal action

(iii) a change in practice location

Other changes must be reported within 90 days.

Finding all these procedures cumbersome and time-consuming? Are you worried about mistakes happening? We are here for you. So set aside your credentialing headaches. Whether it be credentialing, revalidation, or keeping your information current with Medicare, our team will serve you with commitment.

Bristol Healthcare Services delivers the most wide-ranging medical coding and billing services, using advanced technology and experienced staff. We will take care of your credentialing, whether with Medicare, Medicaid, or commercial payors. As a leading medical billing and coding service provider, we always ensure our clients see improved collections. Our in-depth healthcare industry knowledge and experience enable us to provide innovative, end-to-end solutions to successfully resolve our clients’ challenges while enhancing their overall business operations.

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

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