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Don't Be in Denial: Five Key Things to Know About Credentialing and Participation

Aug 20, 2019
Author: Stephen McClure, Contributing Writer, HealthStream

This blog post is based on the webinar that features Penny Noyes, President, Founder, and CEO of Health Business Navigators and Dawn Anderson, PESC, CPMSM; Senior Client Success Manager; VerityStream


In healthcare credentialing, there’s confusion about what it means to be a “participating” provider, which is key to avoiding claim denials. How to ensure providers are participating was the focus of a recent VerityStream webinar presented by Penny Noyes, President, CEO, and Founder of Health Business Navigators.  She has over 40 years of experience on the payer and provider side and is known for her practical, methodical approach to contracting and credentialing,


Five Key Things to Know About Credentialing and Participation


Noyes offered five strategies to help get to the bottom of why participation status may be causing claim denials:


Understand exactly what “participating” or “PAR” means.

PAR (or participating) for a provider means that from the standpoint of a payer you are credentialed, contracted, and linked to the tax ID, the group NPI, the contracts, and the products. However, if you call for verification, the person on the other end of the phone may not be well-versed in the nuances of this status, so it is up to you to get a really straight answer from the payer. Not being PAR can be a result of not being credentialed, not being linked to a contract, or not being linked to a specific payer product, among many additional issues.


Use techniques that connect credentialing and “PAR” status with all contracted payers and products.

Noyes recommends cataloging all contracts with payers and identify the products involved in them. In their contracts many payers will use a generic name like PPO, HMO or “All Payers,” creating confusion about what is marketed as, for example, Blue Elites, Blue Select,etc. Ask your payer contracting reps to clarify all the names of the products involved in the contract. Focus on those details.


Ask specific questions to payers when researching gaps in PAR coverage.

Noyes advises use of a spreadsheet listing every provider with a field for every payer to identify any PAR issues. After asking whether a provider is credentialed, follow-up questions about whether he or she is linked to a contract, Tax ID, dates when effective, and to which specific payer products should follow. If the answer to any of these items is no, find out what’s needed to make it yes. Some important additional questions to ask are:

  • When will the provider be up for re-credentialing? For credentialing in process, find out when it is expected to be finished. Always call back to verify the process is complete.
  • If not credentialed, what is needed to initiate the process? And, is CAQH used by the payer or network? Will the payer accept a roster to initiate the process? If yes, what fields must the roster have?
  • Does the payer/network credential mid-level provider types (like PAs, NPs, PTs, CRNAs, etc.)? If no, how should these be handled?
  • If provider is delegated to another organization, how do you initiate direct credentialing for the provider for your organization?
  • Is credentialing delegated through an IPA/PHO?

Navigate delegated credentialing situations.

Determine whether provider credentialing has occurred through a delegated situation. An example is new providers who came from a group in the same market had delegated credentialing through a big hospital system. Noyes advises the use of direct credentialing to get them added to your group, linked, and PAR to make sure that you don’t run into the problem two or three months later when the previous employer belatedly terminates them. If you delegated your credentialing to an Independent Practice Association (IPA) or a Physician Hospital Organization (PHO), determine which payers and specific plans your providers have opted into. Most IPAs and PHOs have contracts with 5-10 payers and you complete a form for each specifically. Be certain that these groups include all the products you need and identify the effective dates.


Understand how state laws impact government and commercial plans.

Most states do not have laws regarding payer credentialing. Some of them might indicate a timeframe in which a clean application must be reviewed and approved but typically there's no reference to timeframe for linking. No laws involve fines for failure to credential and link by a certain date, which would make payers pay more attention. Noyes singles out Tennessee’s law, stronger than most, which only applies to group commercial agreements and not government plans or individual agreements. The law requires notification for missing info, establishes a limit on how many days to respond, and sets a 90 day timeframe for complete processing. Regardless, Noyes emphasizes the importance of keeping online plan provider directories updated; state laws are sometimes more stringent than CMS regulations in their requirements for accuracy of information.


Ultimately, Noyes advised that the strategies above can help healthcare organizations improve their financial picture by avoiding and fixing the impact of denials and lower out-of-network care payments. Research, perseverance, and diligence are key, as is keeping detailed notes and closely examining transaction and submission reports for clues to PAR issues. Importantly, for managing more than a handful of providers, she also recommended using a tracking and workflow system like CredentialStream to keep track of every step in the credentialing process.