Getting credentialed with an insurance company is an essential part of the process that allows panic providers to bill insurance companies and get paid, which makes the company bottom line healthy. A very popular service used for this process is known as CAQH (Council for Affordable Quality Healthcare). An experienced credentialing company may be able to help with the CAQH process. Many ask, is there insurance credentialing without CAQH? Yes, but there are less efficient and more time-consuming options in more complex scenarios.

CAQH in Credentialing

CAQH is a repository that most providers have to send and keep up to date with their professional profile, including their licenses, malpractice insurance, education and work history, and certifications. Most commercial payers consider CAQH to be the most efficient way of credentialing, and as a result, most insurance credentialing companies and healthcare credentialing companies place CAQH management as a first step in the credentialing process.

CAQH is not a necessity for all payers, as there are some who do not require this service.

When Credentialing Can Be Done Without CAQH

There is no CAQH for some of the following scenarios of insurance credentialing:

Direct Payer Enrollment: Certain payers give providers the opportunity to fill out an application directly in their system, and do not require CAQH to be completed as a part of the credentialing process.

Medicaid Enrollment: Some states have their own online enrollment system for Medicaid. Through separate portals, credentialing specialists are able to handle these processes more efficiently.

Healthcare Credentials: Some credentialing services at hospitals do not require CAQH for privileges because some may do internal medical Staff Credentialing.

Government Programs: CAQH is not necessary for PECOS Medicare enrollments, but there should be consistent information.

Even with these scenarios, players still request most of the same data elements as CAQH. This means the providers have to do the same work over and over again for different systems.

Drawbacks of Credentialing Without CAQH

Although there are some benefits to not having CAQH, the negative aspects outweigh the positives:

Documentation: Providers are required to do more work because they must unautomate submissions of required documents.

Errors: The more work that is done manually, the more errors are introduced.

Duration: Without a central CAQH, verification is . more time-consuming.

Staffing: This is a result of the numerous systems that need to be used and integrated.

This is why most Credentialing services advise to keep a current CAQH profile, even when some do not require it.

Support of Credentialing Professionally

When there is no CAQH, there should be a well-organized system. This is where they excel. They are responsible for the accuracy, compliance and the state of the documents.

To cut down on administrative tasks, many providers will opt to outsource provider enrollment. Insurance credentialing and provider enrollment services point the submission tasks to various payers whether CAQH is involved or not.  

Also, the most reputable medical credentialing companies have CAQH and non-CAQH workflows integrated, giving them the ability to provide real-time tracking across all workflows, which helps them manage delays and improve the speed of reimbursements.  

Is It Advisable to Skip CAQH?

In most situations, skipping CAQH is not a good idea. Most commercial payers require CAQH. Therefore, several medical insurance credentialing services consider CAQH optimization the baseline to enter provider enrollment and credentialing.

There are certain situations, such as some Medicaid enrollments or selective contracting, which may be credentialing without CAQH is acceptable. When it requires the knowledge of insurance credentialing professionals, it's quite rare.

Bottom Line

It is a fact that CAQH credentialing is not a necessity to complete insurance credentialing. In most cases, inefficiencies, administrative burden, and delays in reimbursements will be a result. Solo physicians, group practices, and healthcare facilities can streamline the process with healthcare credentialing companies, which allows them to be certain that their credentialing strategy, whether CAQH-based or not, is compliant, accurate, and centered on revenue.