Credentialing is an essential procedure for healthcare providers who want to be part of insurance plans and care for patients insured by different reimbursement plans. But the timing of credentialing may take much longer or shorter to occur than is much more dependent on the payer. To be able to navigate the credentialing process effectively, it is essential to understand the timeline of the credentialing process and how it varies across various insurance firms, and what factors can be used to alter the credentialing timelines.
This blog will discuss the credentialing timeline by payer, including Medicare, Blue Cross Blue Shield (BCBS), Aetna, and Medicaid credentialing processes. Breaking down the average processing time of each, pointing out shortcut possibilities, the most frequent obstacles to quick approval, and sharing their best practices in following up. As a new or longstanding provider, this guide will assist you in having a more predictable credentialing process to make your enrollment more seamless and quicker.
Average Timelines per Payer
The average credentialing turnaround time per payer is also informative and assists providers in effective enrollment planning. The following are the subheadings and details of every major payer’s timeline:
Medicare Credentialing Timeline
The process of Medicare credentialing entails entry and submission of an application either through the PECOS system online or other traditional means, followed by a review and verification process. The average time that the medical credentialing process takes at Medicare will require is 45 to 90 days, but it may take up to 120 days in exceptional circumstances. Providers are required to submit all documentation needed, which includes state licenses, NPI numbers, liability insurance proof, and the exact submission should be made to avoid delay. Once submitted, the Medicare Administrative Contractor (MAC) will perform the primary source verification and ask us to provide further information to process the application.
Blue Cross Blue Shield (BCBS) Credentialing Timeline
The BCBS credentialing time will also depend on the individual BCBS company in the different states, but it will take approximately 90 to 120 days. This involves checks of credentials, committee approvals, and sign-off on contracts. The decentralised structure of BCBS implies that the applications can be exposed to more paperwork and local BCBS entity steps, which usually results in a prolonged time route.
Aetna Enrollment Timeline
It is normal to take the range of 90 to 120 days to process a provider credentialing at Aetna, depending on the type of provider and the specialty. In the procedure, extensive evidence, verification, and administrative review procedures are involved. Multiple product enrollments (commercial, Medicare, Medicaid) may also have to be satisfied; this aspect can affect the schedule. Aetna also provides electronic application alternatives, which can facilitate the process.
Medicaid Credentialing Process
Timelines establishing credentialing in Medicaid are all over the map because state regulations and system organisation vary so much. It can take 60 to 180 days (depending on the state). The providers need to present a lot of paperwork and go through rigorous verification that can involve background reviews and visitation. Certain states provide alternatives, such as deemed status, that can expedite the process for those providers already credentialed by other payers.
It requires a lot of preparation to satisfy every one of the payers and thus the organisation, and follow-ups are the Key to keeping the credentialing schedule.
Fast-Track Options
Every provider asks the same question: “Can I get credentialed faster?” The answer depends on the payer, provider type, and eligibility for special programs. While fast-track solutions are not guaranteed for everyone, leveraging credentialing services for providers can streamline the process and, when applied effectively, shave weeks or even months off the credentialing timeline.
Medicare Fast-Track Strategies
Medicare is uncompromising and relatively clear-cut on the process of acceleration:
- PECOS Clean Submission: Processing of your application takes place on the PECOS system rather than with paper application forms. Applications by paper may involve a 2–3-month delay. Make sure all supporting documents, such as licenses, DEA registration, and malpractice insurance, are active and are correctly uploaded. The clock of approval goes back to square one even when there is one signature missing.
- Reassignment of Benefits: To reassign your benefits, provide CMS Form 855R when you join an existing Medicare-approved group practice. This makes it possible to bill at the earliest time, as the group is already credentialed.
- Retroactive Billing Dates: Medicare will generally provide up to 30 days of retroactive billing based on the date of application, and in limited, restricted instances, up to 90 days. This reduces the wastage of revenue on rendered patient care before being approved, especially when supported by a reliable medical billing service that ensures accurate claims and timely reimbursements.
BCBS Fast-Track Options
Blue Cross Blue Shield remains infamous for slower credentialing times and has a solution to speed up:
- Delegated Credentialing Agreements: An extensive group practice or Management Services Organisations (MSOs) can achieve credentialing of providers through the mechanisms of delegation of credentials. This can reduce the normal 90 to 120 approval time to 30 to 45 days.
- Provisional Contracting: You can be eligible to see patients immediately with a provisional effective date. First, some BCBS plans issue a provisional effective date after they confirm your CAQH profile and application packet, and it is still pending review by the formal committee.
- Pre-Loading Data: Post applications to multiple state BCBS plans at once when working across state lines (e.g., to BCBS Texas and BCBS Oklahoma). The centralised credentialing offices minimise duplication and accelerate the approval process.
Aetna Fast-Track Options
Aetna’s enrollment timeline is more digital-forward, and in cases where providers leverage the available tools, there is often faster credentialing:
- CAQH Auto-Sync: Aetna also makes use of a lot of CAQH data. Maintaining a clean CAQH profile (no expired licenses or missing attestations) allows you to avoid the time-wasting process of manual follow-up.
- Delegated credentialing: Aetna, similar to BCBS, gives delegated credentialing to large groups and MSOs, where it is possible to onboard sometimes in less than 30 days.
- Provisional Contracting: In some markets, Aetna grants interim network facilities to allow providers to begin seeing patients before formal credentialing procedures are finished.
Medicaid Fast-Track Options
Fast-tracking Medicaid options: Very different from state to state:
- Presumptive or Provisional Enrollment: Provisional Medicaid numbers that are given in some states, such as Florida and Ohio, allow the provider to bill despite the background checks still being pending.
- FQHC and Rural Prioritisation: Federally Qualified Health Centres (FQHCs), Rural Health Clinics (RHCs), and behavioural health centres in underserved locations frequently are given priority processing.
- Medicare-Medicaid Alignment: In some states, Medicaid piggybacks on Medicare credentials, reducing the time frame by weeks should the providers apply to the two concurrently.
Follow-Up Cadence
It is essential to employ a regular and strategic follow-up pace so that the credentialing process can be approved on time. This is how the follow-up with various payers can be managed successfully by providers:
Medicare Follow-Up
Weekly Status Check: Using the PECOS system to monitor the status of your application once each week is critical.
- Prompt Response: Rapid response to any request by Medicare Administrative Contractors (MACs) for further evidence or clarification.
- Document Updates: Ensure that your credentials are up to date and upload any documents that are requested of you promptly.
- Connect with MAC Representatives: Connect with your local MAC representative to get up-to-date information and report severe problems when necessary.
BCBS Follow-Up
- Check-Ins: Check in with the BCBS provider relations or credentialing department every 30 days to check on status.
- CAQH Profile Updates: Maintain an updated and validated CAQH ProView profile and verify frequently, as BCBS will be using this as a primary source of its data.
- Committee Meeting Dates: Ask about when the credentialing committee will meet next, since most of the time approvals are awaiting the committee meetings.
- Delegated Credentialing Communication: In the event you are credentialed under a delegated agreement, it is essential to maintain constant communication with your group or MSO credentialing liaison.
Aetna Follow-Up
- Bi-Weekly Recomanticizing Reports: Review reports every 2-3 weeks with your Aetna provider representative or credentialing coordinator.
- Status Monitoring of CAQH: Manage your CAQH profile and check periodically to ensure your profile is well-maintained to prevent backlogs.
- Application Completeness Assurance: Ensure that your application is received and complete, and promptly correct incompleteness highlighted by Aetna personnel.
Medicaid Follow-Up
- Frequency by State: Medicaid state office frequency of follow-up is highly variable; consider every 30-60 days based on the responsiveness standards in your state.
- Point of Contact: Have a specific contact person assigned in the state Medicaid office so it is easy to talk to someone.
- Provisional Enrollment Check: Ensure full participation, uninterrupted by verifying dates of full credentialing being done in case one is provisionally enrolled.
- Documentation Re-verification: Monitor expiration dates of licenses and documents since Medicaid may demand periodic overall explanations after their first approval.
Conclusion
Medical professionals undergo a long and complicated experience of navigating the payer-specific credentialing lifecycle. The specific processes, schedules, and requirements of Medicare, BCBS, Aetna, and Medicaid can vary significantly in terms of affecting how fast they can make providers credentialed and ready to engage patients.
Although the average credentialing time can vary between 45 and 180 days, based on the payer and the state in which they operate, by educating and applying available shortcut options, as well as matching follow-up cadence consistency, credentialing times can be significantly reduced. Finally, it is essential to be informed and strategic in understanding the individual payer procedures to reduce delays, maximize access to critical patient care, and streamline the reimbursement process.
FAQ - People Also Asks
Why does BCBS take longer?
BCBS can be slower, in that it works off a combination of independent regional plans with different needs and the committee review process in general, whereas other systems, such as Medicare, are more centralised. By managing documentation efficiently and by utilising delegate credentialing, BCBS credentialing may be expedited.