Credentialing Denials

Purpose

It is the clinic’s responsibility to be properly credentialed and to maintain any necessary updates with the payer. Clinicient will perform the steps outlined below on any claims that reach a denied adjudication from a payer due to a credentialing error.

Policy

Post claim adjudication, credentialing related denials will be reviewed to ensure no false denial is received.

The accounts receivable representative will call the payer to validate all information provided in the Payer Tab within Insight Billing.

If no resolution can be established with the payer, documentation showing valid credentialed effective dates will be requested from the clinic to accompany an appeal to the payer. If no documentation can be provided, an adjustment of the claims will be taken no later than the timely filing limit of the payer.

Credentialing Definitions

Credentialing is the process by which insurance networks, healthcare organizations, and hospitals obtain and evaluate documentation regarding a medical provider's education, training, work history, licensure, regulatory compliance record, and malpractice history before allowing that provider to participate in a network.

Why

All payers require credentialing/provider enrollment to avoid fraudulent claim activity and to ensure the providers are maintaining the appropriate continuing education. If a clinic is not properly credentialed, the payer will not pay for services rendered. Most payers (excluding Medicare) do not allow for retroactive billing of services prior to completing the credentialing/provider enrollment process. Billing services under an alternative provider to “get the claim paid” may be a violation of payer policy.

 

Clinicient (the “Company”) is providing this information for general guidance. The application, impact and change of laws can vary widely. Accordingly, the information is provided with the understanding that it is not offered as legal or any other professional advice or services and as such should not be used as a substitute for consultation with professional and licensed advisers. While we have made every attempt to ensure that the information contained herein is accurate at the published time, the Company is not responsible for any errors or omissions, or for the results obtained from the use of this information. All information is provided "as is," with no guarantee of completeness, accuracy, timeliness or of the results obtained from the use of this information, and without warranty of any kind, express or implied, including, but not limited to warranties of performance and fitness for a particular purpose. In no event will the Company or its subsidiaries, agents or employees thereof be liable to you or anyone else for any decision made or action taken in reliance on the information.

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