A Key Step on Your Journey to Provider Status
Over the past decade, many states have passed legislation allowing for advancements towards designation of pharmacists as providers.
The components presented in the legislation vary from state to state, however, these laws generally seek:
- Pharmacist inclusion in health insurance provider networks
- Reimbursement for services provided by pharmacists within their scope of practice
Designation of pharmacists as providers advances the profession and expands pharmacist-provided care to millions of people who are in need of critical services. Pharmacies are emerging from the pandemic as primary care hubs, and pharmacists have an opportunity to capitalize on legislation in their state to serve more needs for patients.
Although passage of these laws grants pharmacists the ability to claim provider status on a state level, additional administrative actions are required by pharmacists before they can be reimbursed for services. This article will discuss credentialing and enrollment, key components in the process of becoming a provider.
What is Healthcare Credentialing?
Credentialing in healthcare is a crucial process of assessing and establishing academic qualifications, licenses, and clinical practice of healthcare professionals. This process helps to ensure that individuals working in the industry are properly reimbursed for certain reimbursable patient care services. However, what is credentialing in healthcare as it relates to pharmacist certification and licensure?
Pharmacy credentialing is the process performed by third-party payers to verify the validity of a pharmacist’s license and to ensure that there are no impending violations against the provider. Substantiating pharmacist credentials is an essential component of acceptance into a provider network.
For example, health insurance providers (e.g. BCBS, Humana, UHC) will verify the credentials for pharmacists which include obtaining a pharmacy degree from an accredited college of pharmacy and state licensure issued by the state board of pharmacy. Validating credentials is necessary to obtain reimbursement for services provided to their members.
Pharmacist Medical credentialing provides reliability and trust for the practitioner. Pharmacy credentials allow patients to trust in their pharmacy provider as well. As patient care services expand and reliance on pharmacists as healthcare providers increases, the need for verifying pharmacist credentials also increases.
The Pharmacy Credentialing Process
Healthcare credentialing for pharmacists can be a complex process, however, it is one of the essential steps for reimbursement of healthcare services. It is one of many steps used to ensure patients receive the best standard of care.
In order for pharmacists to be eligible for practice, they must obtain either a bachelors of pharmacy (BSPharm) or doctor of pharmacy (PharmD) followed by state licensure in the state they intend to practice. To obtain state licensure, the pharmacy candidate must successfully pass two licensing exams:
1. The North American Pharmacists Licensure Examination (NAPLEX)
2. The Multistate Pharmacy Jurisprudence Exam (MPJE)
Additionally, some states may mandate an additional exam known as the Prescription Compounding and Pharmacy Practice Exam.
Enrollment in a healthcare network is the next step following obtaining state licensure.
What is Healthcare Credentialing Enrollment?
Enrollment is the process in which a provider registers within a health plan provider network. Enrolling in a health plan provider network allows the pharmacist to join a list of validated healthcare providers and hospitals with whom a plan contracts to provide healthcare services to the members within the network.
The health plan’s internal claims processing system will verify the identity of the healthcare provider to make a payment determination once a claim for reimbursement is submitted.
What is the Healthcare Credentialing Contracting Process?
Contracting is the legal process to establish a relationship between a health plan and a provider. This occurs once a provider is credentialed and enrolled within a particular health plan’s provider network. Contracts typically include information such as terms of participating in the provider network and reimbursement rates.
Enrollment within a health plan by a provider with verified credentials helps to ensure that the provider’s reimbursement claim will be paid.
Streamline Your Medical Credentialing with DocStation
As pharmacists continue to expand their ability to perform and receive reimbursement for patient care services, qualifications in the pharmacist provider’s scope of practice, skills, and licensure become increasingly important. Credentialing provides patients, payers, and institutions assurance that the pharmacist is a qualified provider.
Unfortunately, the process of credentialing and enrollment with health plans can be very time consuming, complicated, and burdensome.
Luckily, the team at DocStation can guide you. Reach out to us if you need direction credentialing and enrolling or aid completing forms, submitting final credentialing documents, and processing enrollment documentation.
Contact our team at firstname.lastname@example.org to start the process.
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APhA. “Credentialing in the Pharmacy Profession: An Overview of the Current Environment.” May 2022. Accessed November 21, 2022.
Clark, Lindsey. “Credentialing and Privileging 101: A Primer for New Practitioners.” ASHP. May 24, 2016. Accessed November 21, 2022.