Credentialing and Contracting
About Credentialing and Contracting
Credentialing verifies a healthcare provider’s qualifications (license, education, etc.), while contracting establishes the financial and operational agreement with an insurer for reimbursement, with contracting typically following successful credentialing. Credentialing confirms a provider is competent and safe to treat patients, whereas contracting sets the specific rates, terms, and conditions for payment from an insurance company, allowing providers to get paid for services.
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Credentialing
What it is
The verification process by an insurer to confirm a provider's legitimacy, competency, and adherence to standards.
Focus
The individual provider's qualifications (education, licensure, certifications, background).
Outcome
Approval to be considered for network participation, but not yet guaranteed payment.
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Contracting
What it is
Negotiating and signing a formal agreement (contract) with an insurance payer.
Focus
The business relationship, including reimbursement rates, fee schedules, and billing processes.
Outcome
Allows credentialed providers to bill the insurer for services at agreed-upon rates.