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credentialing

Janice Posted Mon 13th of February, 2017 13:58:00 PM
i have a doc thats not credentialed yet with all insurance companys, but hes been reading echo"s at the hospital how do i bill those out please
SuperCoder Answered Tue 14th of February, 2017 06:29:24 AM

Hi Janice,

We need to pay close attention to our payer contracts in order to bill for non-credentialed providers correctly. Some insurence companies may allow not credentialed providers to bill under hospital/clinic name.

Below are different scenarios that one should keep in mind before billing non-credentialed provider.

If your new provider is not replacing anyone and if the health plan requires only credentialed clinicians provide services, you cannot bill for services rendered by that provider. A practice would be in violation of their contract with the health plan if they billed for services not provided by a credentialed clinician or by a credentialed substitute filling in for a previously credentialed provider (even if the contract is under the practice’s name).

In some cases, the health plan will only require physicians be credentialed; in others, plans require all providers (physicians and mid-levels) be credentialed and tied to the contract.

On the other hand, you can bill under clinic name for new clinicians if the health plan does not require individual credentialing. In those cases, most health plans just need an updated roster of providers offering services under the clinic agreement. Hope  it helps.

Janice Posted Tue 14th of February, 2017 13:02:50 PM
the doctor has just joined the practice but is allowed in the hospitals for the group he is credentialed with some insurances but we are still waiting for the rest to join can i bill under the group npi and put him as rendering???
SuperCoder Answered Wed 15th of February, 2017 02:44:34 AM

Hi Janice,

Yes, you may bill under the group npi and send updated roster of new providers/ resently joined provider offering services under the clinic agreement and inform your payer regarding the same. Thank you.

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