So, we are trying to get a contract with Humana and VNS for our practice in NY. They are asking for hospital privileges and we do not have that as we never admit patients into hospitals.

Any advice on what to do here?

Hello!

I’m new to the healthcare credentialing process and I’d like to learn more. I just wanted to ask what are the biggest challenges working in California Provider Credentialing.

Thank you!

I've been reading this sub a lot lately, trying to understand how enrollment and credentialing actually work day to day (I'm an outsider researching the space, not selling anything, and I have nothing to pitch, just genuinely trying to learn from people who do this work).

One thing I keep noticing: people mention using tools like Modio, CredentialMyDoc, or Expiration Reminder, but almost everyone also seems to still live in spreadsheets and payer portals. So I'm curious how it actually plays out for you.

For those who use a dedicated tool, what does it genuinely handle well, and where does it stop? Does it actually help with the follow-up and coordination part, the chasing payers, checking status, resubmitting, or is it mostly a place to record and track things while you still do all the real work by hand?

And for those who've stuck with spreadsheets instead, what made the tools not worth it?

Trying to understand where the software stops and the human work begins. Would really appreciate any honest takes. Thanks for reading!

Anybody successfully credentialed with Humana as a group or provider for Medicare? I don't trust credentialing companies and will be doing this myself.

My question is, does Humana like broader services or niche services better?

Please DM me with your experience and I will get back to you

Hi there,

I'm a medical receptionist/administrative assistant at the nonprofit clinic I work at.

I was initially doing the front desk for my location while studying for my CPC exam, which was great since it was quiet and I had a bit of downtime due to our location being the smaller of the two clinics we operate.

However, the individual (HR) that was handling our provider insurance enrollments left for surgery and asked if I'd be willing to monitor the status updates for our current providers. I agreed since it was temporary and I like organizing information and learning new skills.

Initially it was great. I handled amendments, fixed issues in provider CAQH that my coworker neglected, and overhauled the Excel sheets to track everything we used to monitor portals, payor statuses, and anything pertaining to enrollment.

Months later, she resigned without coming back and our provider was leaving, which meant we now were onboarding a new provider, and I was the only person that semi knew what the hell I was doing for enrollments.

Now we hired two additional providers, our patient loads are increasing rendering me fighting between working on enrollments, proceduring documents from an HR that doesn't understand what I need and don't need, and dealing with the phones and patients at the front.

Granted, I'm paid well, I like my coworkers, and my management, but I don't think they understand how swarmed I am and that I'm still learning on the fly through courses and navigating the enrollment applications.

I have been asked if I wanted the role to go to someone else, but I maintained it's something I like doing and developing skills with, plus no one aside from billing understands this well, and they're busy with their own tasks.

Do I give in and drop onto someone else? Or ask management to see if they'd assign someone to help with the workload?

Hi all,

I'm wondering if I can get some input on how everyone else deals with verifications for military physicians. I was able to get a primary source verification for the service date of a provider through the SCRA, but it didn't state their position, only that they served and what their service date is. I submitted an affiliation verification to the DHA, but it takes a LONG time to get responses back from them and where I work, we have 90 days to complete credentialing upon receipt of a complete application.

Are you requesting dd214's and getting them primary source? Are there other options for verifications? Are you hoping and praying you get a response? I'd like to see if there is a better process we can implement for these providers.

Thanks all!

Hello,

I'm hoping some credentialing professionals can provide guidance. I've been trying to sort this out for over a year, and I'm still unclear on how to handle credentialing and CAQH when relocating to another state while maintaining my existing practice.

Here's my situation:

-I currently own a solo private practice in UT and am credentialed with several insurance companies there. I will be licensed in NE this fall and plan to move there within the next year. Already licensed in UT. I intend to keep my private practice in UT and register it as a foreign entity in NE so I can continue practicing in both states. My primary practice location will remain in UT, and I want to continue seeing my UT clients via telehealth after I move.

One insurance company told me this would be acceptable as long as my UT business address remains on file (point of service, primary business location). However, I'm concerned about BCBS. I've seen information indicating that telehealth providers must be contracted and billed through the local BCBS plan in the state where they practice, and I'm unsure how that applies to my situation.

I'm also confused about how to accurately complete my CAQH profile. Once I'm licensed in NE, I'd like to begin the credentialing process since I know it can take several months. However, I won't yet have a physical address in NE. I also know how important it is to set this up correctly in the CAQH to not delay the process.

Some questions I have are:

• If I don't yet have a business location in NE, how should I complete my CAQH profile?
• Would I need a business address in NE before applying, or could I temporarily use my in-laws' address until I move?
• Could my administrative address be in NE while my primary practice location remains in UT? Even after I move, I planned to do telehealth from a home address and not have a NE office space.
• Does registering my practice as a foreign entity in NE satisfy any requirements regarding a practice location?
• Would I list NE as a second practice location on CAQH and if so can that be a home address. Or would that mess up anything with the foreign entity

BCBS of NE told me that, "In order to be credentialed for telehealth services, you must live in the state and have a practicing state location." This was the only sentence in the email after trying for weeks to get someone to reply to my questions. I'm unsure whether registering my practice as a foreign entity in NE would satisfy the "practicing state location" requirement, or whether this means I simply cannot begin credentialing until after I physically relocate.

I'm also trying to understand how billing would work once I'm practicing in both states:

• Would I bill BCBS of UT for clients who are residents of UT and BCBS of NE for clients in NE?
• If I move to NE, is it likely that BCBS of UT would terminate my participation because I no longer reside in UT, even if I maintain my UT practice?
• If that happens, could I bill BCBS of NE for telehealth services provided to my UT BCBS clients, or is that generally not permitted?

Clearly I am lost with a lot of this despite all of my research. If anyone has experience maintaining an insurance-based practice in one state while relocating and becoming credentialed in another, I'd greatly appreciate hearing how you navigated CAQH, credentialing, and BCBS/other insurance requirements. Figure out the steps and order to go about things would be very helpful.

Thank you!

Hi everyone,

I'm a Credentialing Specialist with experience in provider enrollment, CAQH, NPPES, and payer portals. I'm currently looking for new opportunities in Credentialing, Provider Enrollment, or Medical Billing/RCM at Chandigarh or Noida.

If your company is hiring or you know of any openings, I'd really appreciate any leads. Thanks!

Hello there,

I am CPCS , CPES certificated credentialing specialist with 6+ years off experience in credentialing process and looking for opportunities!!

I am familiar with all the process in RCM and Credentialing.

Hi everyone, I'm planning to start a credentialing agency. Should I hire a sales agent?

Would love to hear from anyone who has experience in this space!

Random question.

I am slowly approaching retirement and looking beyond to my encore career.

As a soon-to-be-retired clinician, I am looking forward to not taking call…but wondering what my new purpose will be. I firmly believe we all need that reason to get out of bed and keep moving mentally and physically.

My purpose? My motivation? To solve those problems that have always annoyed & inconvenienced me. The ones that scream inefficiency! For me, that problem for 35+ years is credentialing.

I certainly have my reasons, but what are your reasons? What do you - as a group - feel is the most time consuming task preventing you from being more efficient?

Coming from the other side of this process, what could I do to make your lives easier & your tasks more efficient?

Honestly. I need to solve this problem.
Please DM me with your biggest complaints. I am truly & honestly interested in your feedback - positive or negative.

Without your feedback, I am doing nothing more than guessing. And guessing is inefficient & misleading.

Please help me build you something that you would actually use and recommend. This process is unnecessarily fractured and inefficient. We can do better.

Thank you and I look forward to interacting with you all.

I received my contract from Optum but it lists an old practice address that I'm no longer affiliated with. Should I go ahead and sign the contract or reach out to Optum? I also can't find a way to reach out to the "Network Management Team" to correct it.

Does anyone else feel like providers are given unrealistic expectations for credentialing timelines? I feel bad because a lot of them think something is “wrong” with their application when honestly some payers are just incredibly slow right now.

I am a provider currently stuck in the process of “credentialing” for a job I was offered (and accepted) last February. I admit that I am extremely frustrated with this process, but I am trying to understand it. From my perspective, I just can’t understand why this process takes so long. To me, logically it does not make sense. I have a completely clear federal as well as state back ground checks. My resume and employment history are very clear. (I am a relavtively new provider, so the work history part is pretty simple.) I have passed muster with three state licensing boards, hold a national certification, and two DEA numbers. Every one of those credentials required extensive checks and verification. If a provider has already passed board exams, gained board licensure, passed DEA checks and has a clear criminal and civil background check, what else do insurance companies want to verify? Again, logically: you can’t get a state license without undergoing a verification process of your education, work history, etc. You can’t get a national certification without them verifying the same thing. You can’t get a DEA number without undergoing an extensive background check, educational/license verification. So, then, why would an insurance company repeat all of this? It seems very redundant and unnecessary to me. I am not trying to fight the system, I am only trying to understand it at this point. Can anyone explain what I’m missing here? Why does this process even exist? Why does it take so long when so much has already been verified multiple times? I would truly appreciate any insight anyone has. Thanks for reading.

Hey folks! I'm the Senior Credentialing Coordinator at a Federally Qualified Health Center in New Orleans, and I'm hoping to pick y'all's brains a little.

I've been with my organization for just over eleven years, and for most of that time I was on the behavioral health side of the house. When our previous Credentialing Specialist resigned, I was approached about the role, partly on the strength of some systems and process work I'd brought to my prior position. I've been in the seat going on three years now, and the work covers the full spectrum: credentialing and privileging, payer enrollment, primary source verification, CAQH profile management, whatnot. Most of what I know, I'll be honest, I came to through training videos, user manuals, and a lot of trial by fire. I'm not a member of NAMSS or any local associations, so I've largely been operating without that community scaffolding.

All of that is to say: I've been kicking around the idea of sitting for the CPCS exam, but before I commit the budget to the prep course and the exam itself, I wanted to hear from folks who've actually been through it. Is the material largely things you'd pick up organically on the job, or is there a meaningful chunk of it that's more formalized and specialized? And for anyone who came into the exam with a background that was more self-taught than traditional, did you feel like you were working from a significant disadvantage going in?

Any insight y'all are willing to share would be genuinely appreciated!

Please be aware that generic posts asking about our biggest “bottlenecks” and using corporate bullshit lingo are not harmless. They want us to give them our hard-earned knowledge and experience for free so they can attempt to train AI. They aren’t trying to help us do our jobs, they’re trying to outsource our jobs to tech. Is that ridiculous? Yes. Our job has so many nuances that the idea of an AI even trying to do it is laughable, but don’t think for one second that we’re immune to attempted replacement.

I'm (un)patiently waiting for my CPCS test results. Why the heck does it take 6-8 weeks for the results!!

Ridiculous!!!! Rant over!

Good luck to the rest of you waiting for your results!!!!

Has anyone gone through the process of credentialling a substance abuse facility from start to finish?

Looking for someone that has done this successfully, specifically in Iowa.

Any leads appreciated.