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Aetna Provider Credentialing: A Step-by-Step Guide

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01/23/2014

We’d like to tell you how you can enroll your clients to become participating providers with Aetna.

Advantages of being a participating provider

Why should your clients go through the credentialing process? Here are some advantages to becoming an Aetna participating provider:

  • They’re listed in our online provider directory, DocFind®
    • Not only can our members find them, but so can other providers who’d like to refer to them
    • Access to our members potentially means more patients for them – and more money for you
  • They can get access to tools which are available only to our participating providers on our secure provider website. These tools can be used for tasks like looking up claims policy information or accessing our Provider Payment Estimator

What’s credentialing anyway?

Credentialing is the process we use to evaluate whether or not a provider is qualified to join our network. We look at a number of items including, but not limited to:

  • Qualifications – education and training, including certifications
  • History
    • Practice
    • Personal conduct
    • Malpractice
    • Disciplinary actions or loss or limitations of hospital privileges
  • Liability coverage
  • Licensure

We go through the initial credentialing process when a provider first applies, and we go through a recredentialing process at regularly scheduled intervals thereafter. We follow guidelines set up by individual states and other organizations, such as the National Committee for Quality Assurance® (NCQA).

How to apply

Here are the basic steps to apply for participation:

  1. Request an application here
  2. We’ll determine eligibility based on if we need a provider in that specialty/service location; if we won’t be able to credential the provider, we’ll send them a letter
  3. If eligible and your client is registered with the Council for Affordable Quality Healthcare (CAQH), we’ll get their application from their website
    • Providers registered with CAQH can complete applications on their site; just make sure your client authorizes us to access their information
    • If your client isn’t a CAQH member, we’ll create a CAQH ID number and forward them a new provider registration kit
  4. Once we receive the application, we’ll start working on it; it takes us about 45 days unless state laws say we need to process it faster
  5. When the provider is approved, someone from our Network Management area will let them know

Why we use CAQH

The CAQH application allows providers to be credentialed and recredentialed using one standard application instead of having to complete separate applications for each health plan. It saves you time.

If you have credentialing questions, you can call our Credentialing Customer Service Department at 1-800-353-1232. For all other questions, please send us an e-mail from the Contact Us link on Aetna.com.