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Everything You Need to Know About Credentialing and Enrollment

This article walks you through the credentialing and enrollment process, how they work at Rula, and how to ensure your information is up to date so that you can continue seeing clients with Rula.

 

What is credentialing?

Credentialing is the process that allows providers to treat within a given network or group. It includes a review of all held licenses, education, employment history, certifications (if applicable), liability policies, and more. Providers must be credentialed by Rula before they can begin enrollment with payers. 

Most of this information is stored in your CAQH Profile, where our payers can easily access it for the enrollment process. 

Rula performs credentialing every 3 years (on average) to ensure no new issues have occurred and providers are still qualified to treat clients—this process is referred to as “re-credentialing.” In order to help ensure that re-credentialing is approved, providers need to keep their CAQH, certificate of insurance, and licenses up to date.

 

What is the difference between credentialing and enrollment?

Credentialing is the process of verifying that a provider is able to deliver care. It typically involves reviewing education, training, certifications, licenses, and work history. 

Enrollment is the process of joining our partner health insurance networks. Once you are enrolled, you’re added to a network’s directory so patients can find you, see that you’re “in-network,” book appointments with you, and you can be reimbursed for services.

Note: Enrollment can’t happen without credentialing being completed first, which is why the credentialing process is so important!

Maintaining your credentials and your CAQH Profile are the biggest parts of credentialing, and as long as everything is up to date, you are in compliance with Rula’s and our payers’ policies.

 

What do I need to do? Doesn’t Rula handle my credentialing and enrollment?

While Rula handles your network approval and maintains your enrollment with our insurance partners, we can’t handle some information, such as your license, NPI number, and liability policy. Providers are responsible for maintaining their personal licenses, policies, and CAQH profile - but don't worry, we're here to help answer any questions you may have!

Here’s what you’ll want to keep updated:

Attesting your CAQH Profile

  • Your CAQH profile must be current and re-attested every 120 days to verify your information and data are still accurate.
  • See this article to learn more about accessing your CAQH profile.
  • See this article for more information about CAQH in general.

Renewing your license

  • Take advantage of our CEUs available to our active providers!
  • Be sure to check your state board for any new requirements prior to renewal.
  • Renew your license before the expiration date, in case there are issues regarding requirements, payments to your state board, etcetera. If your license expires, you can not see patients until it’s showing as renewed on the online state board.

Renewing your Professional Liability Policy

  • It must be an individual policy, not a group policy. If you are the owner of a private practice, we will accept the Certificate of Insurance for that practice if you are listed as the owner on the document.
  • It also must be a professional liability policy, not general/commercial liability, since general liability only covers the location, not you as a provider.
  • See this article to learn more about liability insurance.

Keeping the information connected to your NPI number up to date via the National Plan and Provider Enumeration System (NPPES)

  • You can update your NPI number by visiting the NPPES website. 
Note: Always look for emails from credentialingteam@rula.com. We may need additional information or a specific document for our records or for a payer.

 

What is a CAQH Profile?

CAQH stands for the Council for Affordable Quality Healthcare, and it’s a program that keeps track of all the data required to credential and enroll you with a payer. This system replaced the old paper applications a provider would have to fill out and submit one-by-one to each payer. 

CAQH Profiles need to be “attested” every 120 days, meaning that a provider needs to log in and verify that all of the information entered is still correct, and all necessary documents (such as a current liability policy) are uploaded. Once you have updated all information, click the red “Attest” button. CAQH will send you an email reminding you of when your profile needs to be attested. 

Note: Even if you saved your new information, Rula and our insurance partners can’t see the updated information until you attest your profile. 

 

What do I need to keep updated on my CAQH Profile?

Your CAQH Profile is organized via a menu/tab system with the following sections.

Personal Information

  • If necessary, update your name (e.g., if you get married, change your name and add your maiden name as an alias.)
  • In the “Other Practice State(s)” section, make sure to include all states you practice in.

Professional IDs

  • License expiration dates and issue dates
  • Include any licenses you currently have, or historically had (there is an option to label a license as “Inactive” for licenses you no longer maintain).
  • Add any new licenses you obtain 

Specialties

Update expiration dates for specialties

  • Note: Typically a licensing board is not considered a specialty board, so do not mark “Yes” for “Board Certified?” unless applicable 

Practice Locations/Credentialing Contacts

We may make changes to our Practice Location information, and it will need to be updated. Please keep an eye on your inbox for any requests to update our information! We’re also always happy to update it for you if you provide logins.

Professional Liability Insurance

Add any renewed/new policies, and remember to upload a copy of the Certificate of Insurance in PDF format in the Documents tab!

Employment Information

This should always match your resume with accurate months and years.

 

Here’s a screenshot of the CAQH Profile menu/tab system.

Profile Data.png

 

What is my NPI? What is the NPPES?

Your individual NPI number acts as an SSN for providers and is used in claims processing. Any discrepancies between the information connected to your NPI number and your license may cause issues with processing claims. 

  • NPPES stands for National Plan and Provider Enumeration System; it’s a Federal system developed by CMS (Centers for Medicare & Medicaid Services) that assigns providers their NPI numbers. You can log in and update your NPI via the NPPES website: https://nppes.cms.hhs.gov/#/ 
  • Be aware that any information you enter for your NPI is public information (excluding your SSN for verification purposes), so do not enter your home address as your practice address.

 

What parts of my NPPES record do I need to keep updated?

Identification

  • Ensure that the name listed on your license matches the name attached to your NPI number.
  • Always use your full legal name, not a nickname. Titles such as “Dr.”, or “Mrs.”, should also be excluded (since it won’t appear on your license).  

Mailing/Practice Location Address(es)

  • Ensure practice locations and mailing addresses are up to date, payers will use these addresses to send communications to you. 
  • As of 04/03/24, NPPES will now accept a PO Box as a Practice Location address if a provider doesn’t have an office location. 

Other Identifiers & Licenses

  • Other identifiers such as your Medicaid number should be entered here. 
  • Ensure that any licenses you hold are entered correctly, along with the corresponding state and taxonomy. 

Updating your NPI number can be confusing, but the NPPES Customer Service team is wonderful at walking you through how to make updates. They can be contacted at 866-484-8049.

 

Have Questions?

Please keep in mind that the Credentialing and Enrollment teams can only be reached by email.

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