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INTRODUCTION

In your new role as an NP you have the additional responsibility of providing patient services and generating revenue from those services. After the service has been provided, you will need to bill for that service and then submit that bill to the appropriate insurance carrier in order to be reimbursed. Part of the ability to generate revenue is being credentialed by the individual insurance carriers.

The credentialing process must be completed for you to be able to bill and receive payment for your services. In order to complete the insurance credentialing applications, you must be a graduate of a NP program. The NP program can be a master’s, post-master’s, or Doctorate of Nursing Practice (DNP) degree. Next you must successfully pass your national certification exam as well as be licensed in your respective state. You will also need to be employed as an NP. A practice address is necessary as this where the reimbursement funds will be submitted to.

If you are employed in a hospital setting, the insurance enrollment and training process, or the credentialing process, may be considered part of your on-boarding procedure. If you are employed in a private practice setting, frequently this credentialing process is performed by the practice/office manager. Most of the insurance or third-party applications are available online. Applying for third-party reimbursement may take weeks to months to complete before you are on the multiple provider panels. Attention to detail in completing the applications is essential to avoid delays in the credentialing process. Even if you are not the individual required to complete these applications, being familiar with them is important. Providing the practice manager, or designated individual, your curriculum vitae will assist them in performing the insurance credentialing process. The insurance credentialing process is often confusing for NPs. Becoming familiar with this process enables you to provide informed follow up if needed, as well as making sure you are a provider on all of the appropriate plans.

NATIONAL PROVIDER IDENTIFIER (NPI)

The first step in the insurance credentialing process is completing the application for an NPI number. The NPI number is a unique 10-digit number used to identify healthcare providers. The Health Insurance Portability and Accountability Act (HIPPA) of 1996 mandated a standard set of unique identifiers for healthcare providers and healthcare plans. The actual implementation of the application process began in May 2005.1 The purpose of the NPI number was to improve efficiency and effectiveness of the electronic transfer for health information.1 The implementation of the NPI number was also intended to reduce costs as it was developed to streamline the electronic claims processes for providers. Centers for Medicare and Medicaid Services (CMS) developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.

To be eligible to apply for an NPI number for the first time, NPs must ...

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