#credentialing process

Start your credentialing process today to ensure you're ready to see patients right away.

Why Start Now?

Avoid Delays: Credentialing takes months, so starting early ensures you're ready on day one.

Maximize Revenue: Being fully credentialed means no missed income from insurance delays.

Peace of Mind: Focus on launching your practice, while we handle credentialing.

How MBC Can Help:

Medical Billers and Coders (MBC) manage the entire credentialing process, from paperwork to tracking.

As a healthcare provider in Pennsylvania, enrolling with the Department of Human Services (DHS) is essential to ensure that you can provide necessary medical services to the state’s Medicaid beneficiaries. Provider enrollment involves completing an application, submitting documentation, and meeting eligibility requirements. In this article, we will explore provider enrollment DHS in Pennsylvania and provide guidance for healthcare providers looking to enroll or revalidate their enrollment.

Why Enroll with DHS?

DHS manages the Pennsylvania Medical Assistance Program, which is the state’s Medicaid program. Provider enrollment DHS allows healthcare providers to participate in the program and provide medical services to eligible beneficiaries. Enrolling with DHS also ensures that healthcare providers receive payment for the services they provide to Medicaid beneficiaries. Providers must bill Medicaid for covered services, and payment is made directly to the provider. Medicaid payments can be an essential source of revenue for healthcare providers, particularly those serving underserved populations or in rural areas.

Provider Enrollment DHS Process

The provider enrollment DHS process with DHS involves completing an application, submitting documentation, and meeting eligibility requirements. The process can take several weeks to several months, depending on the complexity of the application and the completeness of the documentation submitted.

1. Application

The first step in the provider enrollment DHS process is completing an application. DHS provides an online enrollment portal, where providers can complete and submit their applications electronically. The application requires information such as the provider’s name, address, and contact information, as well as information about the provider’s practice or facility.

2. Documentation

Once the application is submitted, DHS will request documentation to support the provider’s eligibility to participate in the Medicaid program.

Required documentation may include:

Proof of state licensure or certification

DEA registration (if applicable)

Malpractice insurance

Medicare enrollment (if applicable)

Criminal background check (if applicable)

DHS may also request additional documentation, depending on the provider’s practice specialty or other factors.

3. Eligibility Requirements

To participate in the Pennsylvania Medical Assistance Program, healthcare providers must meet certain eligibility requirements.

These requirements include:

Having a valid license or certification to practice in the state

Meeting all applicable state and federal regulations related to the provider’s practice or facility

Accepting Medicaid payment as payment in full for covered services

Maintaining accurate and complete medical records for each patient

Providers who meet these eligibility requirements and submit all required documentation can expect to be enrolled in the Medicaid program within a few weeks to a few months.

In-network providers generally cannot balance bill patients. When a healthcare provider participates in an insurance network, they agree to accept the insurer’s contracted rates as payment in full for covered services. This means that the provider cannot charge patients for the difference between their usual fees and the lower rates negotiated with the insurer. An in-network provider balance bill occurs when a patient receives a bill from a healthcare provider who is supposed to be in their insurance network, but the bill is higher than what the insurance company has agreed to pay the provider. This happens when the provider bills the patient for the difference between what the insurance company pays and what the provider believes they are owed.

For example, let’s say a patient goes to an in-network hospital for a procedure that costs $10,000. The insurance company has negotiated a rate with the hospital for $8,000. The hospital bills the insurance company $8,000 but then bills the patient an additional $2,000 to cover the difference. This is a balance bill, and it’s an issue that can be very frustrating and expensive for patients. Balance billing is most commonly associated with emergency room visits or out-of-network providers, but it can also happen with in-network providers. It can occur when the provider feels that the insurance company’s payment is not enough to cover the costs of the services provided, or when the provider disagrees with the insurance company’s determination of what is covered under the patient’s plan.

In-Network Provider can Balance Bill

As mentioned above, in-network providers are healthcare providers who have agreed to accept the negotiated rates set by an insurance company. However, there are cases where in-network providers may balance bill their patients, which can result in unexpected and costly medical bills.

Becoming an in-network with insurance companies means that a healthcare provider has contracted with multiple insurance companies to provide healthcare services to the insurance company’s members at a negotiated rate. When a healthcare provider becomes an in-network provider, they agree to accept the insurance company’s reimbursement rates for covered services, which are typically lower than the provider’s regular rates. In exchange, the insurance companies lists the provider in its network of providers and directs its members to seek care from those providers to receive the highest level of insurance benefits.

By becoming an in-network provider, healthcare providers can expand their patient base and ensure that their services are accessible to a wider range of patients who are covered by these insurance companies. This can be beneficial for both the provider and the patient, as it can result in lower out-of-pocket costs for patients and increased patient volume for the provider. Following are general steps to become in-network with insurance companies:

Becoming In-Network with Insurance Companies

1. Obtain NPI and Other Necessary Credentials

Obtaining a National Provider Identifier (NPI) is an important step for healthcare providers who plan to participate in insurance networks. Insurance companies and government programs like Medicare require healthcare providers to have an NPI in order to bill for services. Without an NPI, a provider cannot participate in insurance networks. Providers must be licensed to practice in the state where they will be practicing. This includes maintaining a current license and any necessary certifications, such as board certification.

2. Get Malpractice Insurance

Malpractice insurance is a type of insurance that provides coverage to providers in the event that they are sued for medical malpractice. Becoming an in-network provider often requires malpractice insurance because insurance companies want to ensure that their network providers are adequately covered in case a patient files a malpractice claim against them. Malpractice insurance can help protect healthcare providers from financial ruin by providing coverage for legal expenses and damages that may be awarded to the patient. Even the most skilled and careful healthcare providers can make mistakes, and malpractice insurance can provide peace of mind and financial protection in the event that something goes wrong.