Credentialing
Provider credentialing is the formal process of verifying a healthcare provider's qualifications, licensure, and background to confirm eligibility for insurance participation and reimbursement. ANO-RCM manages every stage of this process so providers can focus on patient care without administrative delays.
Provider Enrollment
ANO-RCM completes and submits enrollment applications for new providers with commercial insurers, Medicare, and Medicaid. We track application status, respond to payer requests for additional information, and follow up through to approval to minimize gaps between a provider's start date and their first reimbursable claim.
CAQH Profile Management
Most major payers require an active and current CAQH profile before enrolling or re-enrolling a provider. ANO-RCM handles initial profile creation and performs ongoing maintenance — updating licenses, malpractice coverage, DEA certificates, and attestation renewals — ensuring the profile is always accurate and never flagged as expired.
Re-credentialing
Payers require re-credentialing at regular intervals — typically every two to three years — to confirm a provider's credentials remain current and in good standing. ANO-RCM tracks re-credentialing deadlines for each payer and initiates the process proactively, preventing lapses in participation status that could interrupt claim payments.
Primary Source Verification
Credentialing requires verifying information directly with the issuing source. ANO-RCM conducts primary source verification with medical schools, residency programs, state licensing boards, the DEA, and malpractice carriers to confirm the accuracy of all submitted credentials and meet payer and accreditation requirements.
Group & Individual Credentialing
ANO-RCM supports credentialing for solo practitioners, multi-provider groups, and practices adding new providers to existing group contracts. We coordinate with payer relations representatives to link individual provider NPIs to the appropriate group NPI and billing entity, ensuring claims route and pay correctly from day one.
Terminology
- CAQH
- Council for Affordable Quality Healthcare — a non-profit organization that maintains a universal provider database used by most major insurance payers as the primary source for credentialing information.
- NPI
- National Provider Identifier — the unique 10-digit number assigned to every healthcare provider by CMS. Individual providers have a Type 1 NPI; group practices have a Type 2 NPI.
- Primary Source Verification
- The process of confirming credential information directly with the original issuing organization (e.g., a state licensing board or medical school) rather than relying solely on provider-submitted documentation.
- PAR (Participating Provider)
- A provider who has been credentialed by and contracted with an insurance payer, agreeing to accept the payer's negotiated rates as payment in full for covered services.
- DEA Certificate
- Drug Enforcement Administration registration — required for providers who prescribe controlled substances and commonly verified during the credentialing process.