What is credentialing?

Credentialing is the process of assessing and verifying the qualifications of a health care provider such as licensing, certification, and education.  Medicare, private payers, hospitals and other organizations credential health care providers including PAs.

What is enrolling?

Enrolling is the process of adding a provider’s credentials to the payer’s system. Medicare and private payers enroll health care providers and payment is rendered only to those providers who are enrolled.

How do I get credentialed and enrolled?    

The first step is to get an NPI number

NPI numbers

The Health Insurance Portability and Accountability ACT (HIPPA) of 1996 requires the use of a standard unique identifier for health care providers.  The CMS (Centers for Medicare and Medicaid Services) developed such a system, called the National Plan and Provider Enumeration System (NPPES).

This unique identifier, termed an NPI number, is a 10-digit number that is assigned to each provider of service and does not contain any information about the provider.  The number stays with the provider regardless of job change or location change.  The NPI fact http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/downloads/npi_fs_geninfo_010906.pdf provides more information.

PAs and NPI numbers

Any entity, including PAs, who meet the federal definition of a “health care provider” at 45 CFR 160.103 may apply for an NPI number.   The NPI numbers do not replace the Medicare enrollment process.  PAs must also enroll in Medicare to receive payment from Medicare.

 Getting an NPI

You can apply for a free NPI number at nppes.cms.hhs.gov or (https://nppes/cms/hhs/gov/NPPES/NPIRegistryHome.do)

To apply you will need your contact and indentifying information (including Social Security Number) and State License Information


Enrolling in Medicare

PAs and Medicare

Medicare claims for PA services may be submitted under the PAs NPI number.  PAs may submit claims under the supervising MD’s NPI number for “incident to” and shared visits.  However, this renders the PA’s services invisible to Medicare and to statistical and research investigations.  All health care providers must enroll directly on Form 855i at www.cms.gov or http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/suppliers.pdf

PAs and Maryland Medicaid

 More than half of the states recognize PA’s NPI numbers and allow for Medicaid services to be billed under the PAs NPI number.   Currently, Maryland requires the services to be billed under the MD’s NPI.


Enrolling with private (third party) providers

Enrollment varies by payer.   Some payers enroll, credential, and allow the PA to bill under their NPI number.  If the payer does not credential PA’s, then the PA should bill under the MD’s NPI number.  However, this will render the PA’s services invisible.  An overview of how private payers enroll, credential, and expect claims to be filed can be found in the section on payer profiles.