Let’s be honest, after years of residency, the last thing you want to deal with is a long, complicated credentialing process. The reality is, getting approved by major insurance networks like Aetna can be a frustrating and time-consuming final step.
The good news? You don’t have to figure it all out alone. At MediBillMD, our experts have created this guide to simplify Aetna credentialing.
Thus, if you want to navigate the credentialing maze with a map in hand, avoiding the dead ends and frustrating U-turns, this guide is for you!
A Step-by-Step Guide to Aetna Credentialing Application
Aetna insurance credentialing involves the following four steps:
Step 1: Request Participation
The first step is to request participation in the network by submitting an online Aetna credentialing form. Note that they offer specific forms for various provider types (behavioral health, dental, or medical) and facilities. Thus, choose the correct form and ensure that all information you provide is complete and accurate.
Step 2: Wait for Network Evaluation
Once you complete the Aetna credentialing form, the insurance company determines whether it needs new healthcare providers in your specific geographic area. This step in the credentialing process ensures that the provider network stays balanced and fulfills the needs of Aetna’s members without being oversaturated.
Note that it is not a clinical decision, but a business one. After this step, Aetna informs applicants whether they are eligible to complete the credentialing and contracting process or not. It typically takes 45 days to come to a decision.
Simply put, this step serves as a gatekeeper, saving time and effort for interested providers and facilities.
Step 3: Submit Credentialing Application
If you are approved to proceed, you will be invited to complete the Aetna credentialing application. Aetna primarily uses the Council for Affordable Quality Healthcare (CAQH) ProView database for this.
Thus, you must have an up-to-date and complete CAQH profile to authorize Aetna as a health plan and access your application. Besides, at this step, the insurance company verifies your professional credentials and background.
Step 4: Sign Contract & Get On Board
After the credentialing process and contract finalization, you will receive welcome materials with the necessary details, so you can start seeing Aetna members.
Aetna Provider Credentialing Requirements
Grab your coffee and stretch if you want, because this section will take you through all the requirements of credentialing with Aetna. Whether you are a medical practitioner, behavioral health provider, dentist, or a hospital, this section will address the key requirements individually to offer better clarity and understanding:
Aetna Credentialing Requirements for Medical & Behavioral Health Providers
The table below discusses the Aetna credentialing requirements for an individual provider or a group practice (not currently participating with Aetna) applying under a social security number (SSN) or Tax ID/EIN:
| Requirements | Description |
|---|---|
| Tax ID Number(s) | If you are a healthcare practitioner with multiple tax IDs, complete the form once for the primary location ID. It will initiate the contracting and credentialing process. |
| National Provider Identification (NPI) Number | In case of Type 2 NPI Group/DBA, you should submit a separate application for each provider in your group. Besides, do not forget to include their Type 1 NPI. |
| CAQH Provider ID | Your CAQH ProView application must be complete to authorize Aetna to access your application. It will also prevent delays in the credentialing process. |
| W-9 Form | Submit a valid and complete W-9 form associated with the new tax ID. Note that the file size should not exceed 2 MB. |
| Currently Enrolled in a Medical Residency Program? | If you will complete your residency in the next 30 days, complete the request for participation.In case your residency ends after 30 days, avoid completing the application. If you still submit it, Aetna will withdraw it. |
The Aetna credentialing process for medical and behavioral health providers has three stages, including information gathering, contacting, and reviewing:
Information Gathering
First, the insurance company collects the provider’s background and qualification details via a formal application process.
Then, they verify the information against reliable sources, including the American Board of Medical Specialties and the National Practitioner Data Bank.
Contacting
In this next stage of credentialing with Aetna, the insurance company contacts key entities to verify the provider’s credentials. These involve the following:
- Licensure – Any state where the physician or behavioral health practitioner holds an active medical license.
- Medicare/Medicaid – To confirm the practitioner is allowed (not banned) to care for patients enrolled in Medicare/Medicaid programs.
- National Technical Information Service – To ensure the practitioner is authorized to write prescriptions.
- Schools and Hospital Programs – To verify training is complete and accepted by the specialty board.
Reviewing
The final step involves a comprehensive background check of the healthcare provider, which includes reviewing the following:
- Aetna Committee Information – To determine whether to include the practitioner in the network.
- Malpractice Claims History – To review past malpractice claims.
- Malpractice Insurance – To confirm active coverage.
- Personal History – To check for any disciplinary actions.
- Hospital Privileges – To see if privileges have been lost or limited.
- Work History – To review the practitioner’s employment background.
The table below discusses the information Aetna collects during the credentialing process:
| Requirements | Description |
|---|---|
| Board Certification | Confirmation that the medical or behavioral health provider is certified by the appropriate board. |
| Hospital Affiliation | A list of hospitals where the provider has privileges. |
| Languages Spoken | The languages the provider speaks. |
| Medical Group Affiliation | Listing the group practice the provider is a part of. |
| Office Status | Indicates whether the provider is accepting new patients. |
| Patient Age Focus | Whether the practitioner has any patient age specializations. |
| Provider Gender | The gender of the medical or behavioral health provider. |
| Provider Information | The provider’s name, phone number, and office location. |
| Specialty | The practitioner’s field of specialty. |
Aetna Credentialing Requirements for Dental Health Providers
The Aetna credentialing process for dentists involves the following steps:
Data Collection
The process initiates when the dentist submits an Aetna credentialing application. The application must include complete professional credentials and demographic information.
Business Criteria
In this next step, the insurance company verifies that the applying dentist falls within their business criteria for network participation.
Primary Source Verification
After the dentist submits the required information, the insurance company begins the verification process. How? Aetna’s Core Dental Credentialing department is responsible for validating all the provided information by contacting sources, including individual State Dental Boards and the National Practitioner Data Bank (NPDB).
In case you are uncertain what the primary source verification requirements are once the Aetna credentialing application is submitted, then the table below will give you a glimpse into it:
| Requirements | Description |
|---|---|
| Anesthesia Permits | Verification of the dentist’s permit to administer anesthesia (if applicable). |
| Disciplinary Actions | Checking for any disciplinary actions taken against the dentist. |
| Malpractice History | Review of claims history to determine any active malpractice of insurance coverage. |
| Medicare/Medicaid Sanctions | A check to determine if the practitioner has been sanctioned by the federal government’s Office of Inspector General (OIG) or Office of Personnel Management (OPM). |
| NPDB Query | A check of the NPDB for any relevant reports. |
| National Technical Information Service (NTIS) | Verification of licenses to prescribe drugs, including Controlled Drug Substance Registration (CDS) or Drug Enforcement Agency (DEA) certificates. |
| State Licensing Boards | Confirming that the dentist’s license is active and free of sanctions. |
Aetna Credentialing Requirements for Hospitals
The credentialing process of Aetna for hospitals involves a combination of self-reported information from the facility and verification against recognized accrediting bodies.
Besides, Aetna requires hospitals to be licensed, maintain accreditation, and provide evidence of adequate professional liability and general insurance through a contract. That’s not all, it also requires facilities to inform about any changes related to accreditation or licensure status.
The following are the requirements for getting credentialed with Aetna for hospitals:
- Accreditations: The hospital must have accreditation with the American Osteopathic Association (AOA), The Joint Commission, or any other Aetna-recognized accrediting entity.
- Insurance: Aetna specifies that any facility that wants credentialing with Aetna must have current professional liability insurance in adequate amounts.
- Medicare Certification: The hospital needs to be Medicare-certified or approved for certification in applicable Medicare markets.
- Reputation: The applying facility must have good standing with all relevant state and federal regulatory bodies and provide evidence of it.
Challenges in Getting Credentialed with Aetna
We have clearly explained the steps to getting credentialed with Aetna, but sometimes navigating through common challenges becomes inevitable for busy providers and facilities.
Thus, this section will discuss the most common issues. Understanding these can help you prevent delays and errors.
Inaccurate/Incomplete Application
Missing, incorrect, or outdated information on your CAQH profile is a common reason leading to a pending Aetna credentialing application status. Beyond delays, it can result in outright rejection.
Delays in Verification
Aetna must verify all the information provided in the credentialing application, including your contact details, background check, and qualification credentials.
Insurance companies typically do this by contacting primary sources such as medical schools, state licensing boards, and past employers. However, sometimes these entities are slow to respond, significantly lengthening the overall Aetna insurance credentialing time.
Expired Certificates and Licenses
Another major issue that can lead to application rejection is failure to maintain current certifications, licenses, and malpractice insurance. Thus, if any of your documents have expired, Aetna has the right to halt the credentialing process.
Gaps in Work History
If you have any gaps in your work experience, you must explain the reason behind them. Failure to do so can also raise red flags, leading to a delayed credentialing process.
Best Practices for Aetna Insurance Credentialing
Now that you have an idea of the common roadblocks providers and facilities encounter in their pursuit of getting credentialed with Aetna, it is time to discuss some best practices. These will help you stay ahead of potential challenges and streamline the overall credentialing process:
Start Early
Are you a new practitioner credentialing with Aetna? If yes, prepare for the process when you have only 30 days left until your residency completion. But do not start it before that, as it will result in outright rejection.
For facilities and established providers, initiate the credentialing process well in advance of your desired start date. The reason? The credentialing process typically takes 90 to 120 days to complete.
Maintain Your CAQH Profile
Do you want to prevent credentialing delays? Then start treating your CAQH ProView profile as a living document. That is, strive to keep it up-to-date and re-attest to its accuracy every 3 months or 120 days. It should be the standard practice even if you are not actively applying for credentialing.
Keep Documents Organized
Another best practice for getting credentialed with Aetna is to maintain a digital folder with essential documents in an organized fashion. These include CV, certifications, licenses, DEA certificate (if applicable), and malpractice insurance letters.
Communicate and Follow-up
Always respond promptly when Aetna asks for additional information. In case you are not getting any news from Aetna, avoid assuming that no news is good news. Instead, strive to follow up regularly to stay current on your Aetna credentialing application status.
Review Your Contract
Here comes the last and most critical tip! Once approved into the Aetna network, review the final contract. Carefully go through the reimbursement rates and all terms and conditions before signing.
Accelerate Your Aetna Credentialing with MediBillMD
This guide touched upon all the key requirements, challenges, and best practices related to Aetna insurance credentialing. However, it is a time-consuming and lengthy process. We understand that as a healthcare practitioner, your hands are already full with clinical duties and documentation requirements. With all this, investing in a daunting task like credentialing can easily burn anyone out.
But worry not! MediBillMD has a separate department that handles credentialing for top insurance companies like Aetna. It comprises seasoned credentialing experts who know how to ensure accuracy and proactively follow up to fast-track the process. Thus, if you need professional assistance, feel free to outsource insurance credentialing services to our experts.
