Medical Credentialing Services
Trusted Credentialing Services You Can Relay On to Meet Regulatory and Payer Requirements.
Provider Credentialing Solutions By PrognoCIS
Credentialing is the process of verifying a provider’s qualifications to ensure that they can provide care to patients. Most health insurance companies require this process including CMS/Medicare, Medicaid, and Commercial plans, as well as hospitals and surgery centers.
Provider Credentialing Documentation and Verification Requirements
The provider’s credentialing process is completed by verifying all of a provider’s documents to ensure that they are valid and current. These include their medical license, malpractice insurance, and DEA. Additional information necessary to complete credentialing:
- Medical School information
- Internship/Residency/
Fellowship’s Information - Board Certifications
- Provider’s CV
Become Insurance-Ready with PrognoCIS Credentialing Services
PrognoCIS Provider Credentialing services, we can assist you with provider enrollment and becoming an in-network provider so that you can receive reimbursements from each carrier. While just a few years ago healthcare professionals considered medical credentialing service “optional” for building a practice, today it has become more necessary than ever for providers to be in-network with insurance companies. Learn how PrognoCIS can help you get the proper credentials to open a medical practice.
Credentialing Made Simple: Fast, Reliable, and Compliant Every Time!
Credentialing Made Simple
Our Credentialing team delivers a knowledgeable and comprehensive service to assist you in becoming an in-network provider with the insurance carriers that you want to participate with. We can give you recommendations by performing analysis for your specialty and service area if you need guidance.
Ongoing Credentialing Support
We also provide services to existing practices. Credentialing providers is an ongoing process and must be redone every 3 to 5 years. PrognoCIS offers a service that will complete re-credentialing, notify you of expiring documents and maintain your CAQH profile.
Start Your Enrollment
When you have your documentation ready, reach out to us. We support practices of all sizes, from solo practitioners to large groups with 30+ providers. We assist with Medicare, Medicaid, and Commercial Payers for group and individual enrollments, with specialized expertise in various specialties and DME services.
Master the Provider Credentialing Process: Step-by-Step to Success
Step 1.Collaboration Is Key
The medical provider credentialing process requires involvement from the healthcare provider, the organization, and the payer.
Step 2. Starting Strong: Application Completion by the Provider
The organization typically provides the healthcare professional with the credentialing application(s). He or she is responsible for completing the application – which may be many, many pages long – and attaching all requested documentation like board certification, college degrees, and more. When the application is complete, the provider submits it to the organization he or she plans to provide services under.
Step 3. Organization’s Role: Verification and Documentation
The organization is then responsible for attaching additional documentation: any claims history, background screen results, primary source verification, and more.
Step 4. Submitting to the Payer: The Final Package
Once they’ve completed any healthcare facility portions of the application and attached appropriate documentation, they submit the completed application and supporting documentation to the payer.
Step 5. Payer’s Evaluation: Meeting the Standards
The payer reviews the application to determine whether the healthcare provider meets the payer’s standards. Things they’ll take into consideration include the provider’s education (and accreditation of that program), residency or fellowship, recommendations, malpractice claims history, license, and more.
Step 6. Not Just Once: Ongoing Credentialing Requirements
This entire process is required when the provider first joins a new practice and then periodically thereafter – usually every two to three years depending on the payer.
What does medical credentialing cost your business? How do you measure this cost?
What You Need to Get Credentialed: A Quick Checklist
Information is dependent on payers but tends to be relatively consistent across the board and typically includes:
- Malpractice claims history (suspensions, revocations)
- License to practice and primary source verification
- NPI number
- License history
- DEA license
- Work history
- Degrees and transcripts
- References from previous
- Employers/practitioners
- Insurance information
- Board certification Copy of Medical License(s)
- DEA Certification
- Board Verifications
- Malpractice Insurance Details
- Curriculum Vitae (CV) (with gaps explained)
- Hospital Privileges (if applicable)
- NPI Number
- CAQH profile
- State-Controlled Substance Certificate
- Completed and Signed Payer Application
Why Smart Practices Outsource Credentialing & Re-Credentialing
The Hidden Costs of In-House Credentialing: Time, Expertise, and Endless Follow-Ups
When you elect to handle credentialing providers in-house, you must assign resources to compile and send out application materials to new providers; track the completion and collect the documents; complete the facility portion of the application and credentialing process (like primary source verification, malpractice claims review, etc.); send the applications to payers; and then respond to any requests for corrections or additional information from payers.
Additionally, that person (or team) must track re-credentialing deadlines and initiate, track, and complete the process every time a provider is due for re-credentialing.
Avoid Delays and Denials: Let PrognoCIS Handle Credentialing with Confidence
Lack of credentialing expertise can result in denied applications or payer delays—pushing back a provider’s start date and impacting patient care. That’s why many healthcare organizations choose to outsource credentialing to experts like PrognoCIS.
At PrognoCIS, we manage the entire credentialing process—from completing provider applications to handling organizational verifications and working with payers to ensure timely approvals. This allows your team to stay focused on patient care while we streamline provider onboarding.
Unlock the Advantage: PrognoCIS Credentialing Services That Work
PrognoCIS Medical Credentialing Services for Providers, offers you the following:
- Credentialing Expertise Across Specialties and States
- End-to-End Credentialing Management
- Faster Provider Enrollment
- Reduced Claim Denials
- Compliance and Accuracy
- Ongoing Documentation Management and Reminders
- Improved Operational Efficiency
Other Credentialing Benefits
Credentialing Is Essential for Revenue Cycle Success
The organization can't bill for the services a professional provides unless that professional has been approved by all payers through the credentialing process. This makes medical provider credentialing a foundational task as providing services that can't be billed is not feasible or sustainable for the organization.
Protecting Patients, Revenue, and Reputation
The credentialing process ensures that the provider meets the standards of the organization and the organization's payers, identifying risk factors early and reducing the risk of adverse outcomes. As a result, credentialing improves the patient's trust in their provider and healthcare organization, protects hospital revenues, limits risk of potential loss, and improves the practice's reputation overall.
Time-Consuming but Worth It
Although credentialing can be time-consuming, delaying the onboarding of new providers and requiring facility resources to process and support, the benefits outweigh the risks in every case.
Credentialing Is Essential for Revenue Cycle Success
The organization can't bill for the services a professional provides unless that professional has been approved by all payers through the credentialing process. This makes medical provider credentialing a foundational task as providing services that can't be billed is not feasible or sustainable for the organization.
Protecting Patients, Revenue, and Reputation
The credentialing process ensures that the provider meets the standards of the organization and the organization's payers, identifying risk factors early and reducing the risk of adverse outcomes. As a result, credentialing improves the patient's trust in their provider and healthcare organization, protects hospital revenues, limits risk of potential loss, and improves the practice's reputation overall.
Time-Consuming but Worth It
Although credentialing can be time-consuming, delaying the onboarding of new providers and requiring facility resources to process and support, the benefits outweigh the risks in every case.
Medical Credentialing Services Options and Details
- Verification of current state medical license and DEA registration
- Updated malpractice insurance documentation
- Review and confirmation of hospital privileges (if applicable)
- Primary source verification of credentials and board certifications
- Updated Curriculum Vitae (CV) with complete work history
- Background checks (criminal history, OIG, NPDB, sanctions)
- Confirmation of continuing medical education (CME) records, if needed
- Re-submission of applications to commercial and government payers
- Review of prior data for accuracy and completeness
- Detailed tracking of application statuses and approvals
- Automated reminders for upcoming expirations and deadlines
Provider Personal Information
- Name changes (if applicable)
- Contact information (phone number, email address, office address)
- Gender or ethnicity updates (if required for reporting)
- Changes in medical specialty or subspecialty
- New certifications or board credentials
- Updates on academic or professional affiliations
- Changes in hospital privileges or clinical appointments
- Renewal of state medical licenses
- Updated DEA registration information
- Updates to malpractice insurance coverage
- New or expired certifications (board certifications, additional training)
- Changes in practice location or multiple office addresses
- Update to business name or Tax ID (EIN)
- Adjustments in payer enrollment or provider number updates
- Updated contracts or payer information
- Change of payer networks or health plans the provider is contracted with
- Submission of Updated Practice Location Information
- Facility-Specific Details
- Updated Applications or Addendum Forms
- Verification of Licenses & Certifications
- CAQH & Payer Profile Updates
- Coordination of Effective Dates
Medicare Enrollment Includes:
- Completion of CMS-855I, 855B, or 855R forms
- NPI (National Provider Identifier) validation
- PECOS (Provider Enrollment, Chain, and Ownership System) registration and application submission
- Reassignment of benefits (for group practices)
- Ownership and management control disclosures
- Submission of supporting documents, including licenses, certifications, and malpractice coverage
- Application tracking and follow-up through CMS systems
- Revalidation and re-enrollment management as required every 3–5 years
- Completion of state-specific Medicaid applications and attestations
- Submission of NPI, CAQH, licenses, and certifications
- Background checks and exclusion list screenings
- Enrollment for multiple service locations if applicable
- Portal setup for claims submission and eligibility verification
- Ongoing renewal and compliance support per state guidelines
- Tracking of the following documents expiration dates
- Medical License
- DEA/CDS
- Board Certifications
- Malpractice Insurance
- Notification of re-credentialing dates
- Updating of CAQH
What’s Inside:
A Breakdown of New Provider Credentialing
- New Credentialing and Medicare Group Enrollment
- Medicare Individual Enrollment and Medicare Revalidations
- Medicaid Group Enrollment and Medicaid Individual Enrollment
- DME Credentialing
- Facility Enrollments
Why Choose PrognoCIS for Medical Credentialing Service?
- We offer yearly maintenance by keeping a close eye on Medical License, DEA/CDS, Board Certs, or anything with an expiration date and track the progress with updating CAQH and NPI.
- Solutions scale from single provider clinics (solo & private practice) to large, multi-site and specialty medical facilities.
- To equip yourself with early risk identification to avoid poor outcomes and meet the high standard sets by organizations and their payers.
- Offer guidance along the way to becoming an in-network provider that reaps reimbursements from each carrier.
- Outsourcing provides savings for Medical Practices.
FAQs
You should expect a credentialing service to deliver accuracy, efficiency, and fully comply with industry regulations. A reliable company will handle the end-to-end process, including application preparation, source verification, payer enrollment, and re-credentialing. They should maintain knowledge of changing payer requirements, ensure timely follow-ups, and reduce administrative burdens on your staff.
Outsourced Credentialing companies should respond to requests in a timely manner and provide excellent communication and complete transparency. A provider should work with a company that is professional and caring, taking ownership in the process as your representative in dealing with the insurance companies.
PrognoCIS offers a comprehensive credentialing service that handles every step from enrollment to recredentialing. Our experts handle documentation collection, application submission, primary source verification, payer communication, and deadline tracking.
The credentialing process typically takes 90-120 days, depending on the payer, provider type, and completeness of the submitted document.
Yes, our credentialing experts have extensive experience in credentialing providers across all of specialties. They are well-versed in the unique requirements of various specialties and state-specific regulations.
Yes, PrognoCIS offers an ongoing credentialing maintenance service that tracks document expiration and contract renewals. We will handle the re-credentialing and re-enrollment process with payers to ensure uninterrupted participation and reimbursement.
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