Credentialing Denials

I am Ahmad Rizwan, Credentialing Specialist. Long story short, here are the facts that indicate the importance of credentialing.

Credentialing Denials:

Remember that not every practitioner has their application approved by the payer's credentialing committee. You may occasionally receive a refusal, which also indicates that the provider isn't going to be a participating provider for an unforeseen period. Any claims made under the name of that provider will be denied. Possible reasoning for denials usually involves:

• Provider failing to release sanctions, limitations, or adverse actions
• Payer credentialing verifications that do not match what was documented and submitted on the provider application
• On occasion, there is a misunderstanding and the payer denies a practitioner by mistake
• Medical malpractice cases showing a trend in clinical negligence
• Payer unable to verify completion of the training program

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