A Guide to Provider Credentialing with Aetna

This process serves multiple purposes:

1. Ensuring patient safety and quality of care
2. Minimizing the risk of medical malpractice
3. Meeting regulatory requirements
4. Maintaining the integrity of the insurance network
   

Initial Application

The credentialing process with Aetna begins with the submission of an application.

Providers can initiate this process through:

1. CAQH ProView / CAQH Provider Data Portal – The Council for Affordable Quality Healthcare’s standardized platform
2. Aetna’s provider website
3. Direct contact with Aetna’s Provider Relations department

Required documentation typically includes:

• Medical license
• DEA certificate (if applicable)
• Malpractice insurance documentation
• Board certifications
• Educational background verification
• Work history
• Hospital privileges
• References

Timeline and Expectations

The credentialing process with Aetna typically takes 90-120 days from the submission of a complete application.

This timeline can vary based on:

• The accuracy and completeness of the submitted information
• The responsiveness of references and verification sources
• The complexity of the provider’s history
• Current credentialing volume at Aetna
  

Maintain Current CAQH ProView Profile

Keep your CAQH ProView / CAQH Provider Data Portal profile up-to-date, as Aetna primarily uses this platform for credentialing.

Ensure:

• Quarterly attestations are completed
• All documents are current and not expired
• Contact information is accurate
• Practice locations are updated

Prepare Documentation in Advance

Gather all necessary documentation before starting the application process:

• Verify that all licenses and certifications are current
• Ensure malpractice insurance meets Aetna’s requirements
• Prepare a comprehensive CV detailing work history
• Have professional references ready to respond

Follow Up Regularly

Stay proactive during the credentialing process:

• Keep a record of all submitted documentation
• Follow up every 2-3 weeks for status updates
• Respond promptly to any requests for additional information
  

Challenge 1: Incomplete Applications

Solution: Use a credentialing checklist and double-check all requirements before submission. Consider using a credentialing specialist or service to ensure accuracy.

Challenge 2: Delays in Verification

Solution: Alert references and previous employers that they may be contacted for verification. Provide accurate contact information to expedite the process.

Challenge 3: Expired Documentation

Solution: Set up a tracking system for license and certification expiration dates. Begin renewal processes well in advance to avoid gaps.

Recredentialing Best Practices

1. Mark your calendar – Set reminders for the three-year recredentialing cycle
2. Maintain documentation – Regularly update your credentials and keep records organized
3. Stay compliant – Address any quality issues or complaints promptly
4. Monitor performance metrics – Be aware of your quality scores and patient satisfaction ratings
   

Different specialties may have additional credentialing requirements:

Mental Health Providers

• Specific licensure requirements
• Additional documentation of specialized training

Surgical Specialists

• Detailed surgical logs
• Hospital privileges verification

Primary Care Physicians

• Patient panel information
• After-hours coverage documentation
  

Aetna has embraced technological advancements to streamline the credentialing process:

1. Online portals for application submission and tracking
2. Automated verification systems for certain credentials
3. Digital document management for faster processing
4. Integration with CAQH ProView for standardized data collection
   

Understanding the financial aspects of credentialing is crucial:

Costs Associated with Credentialing

• Application fees (if applicable)
• Time investment in gathering and submitting documentation
• Potential lost revenue during the credentialing process

Reimbursement Implications

• In-network status affects reimbursement rates
• Retroactive billing policies
• Impact on patient out-of-pocket costs
  

Providers should be aware of the legal implications of the credentialing process:

1. Accuracy of Information – Providing false information can result in serious consequences
2. Disclosure Requirements – Obligation to report adverse events or changes in status
3. Appeals Process – Rights and procedures for appealing credentialing decisions
4. Compliance with Regulations – Understanding state and federal requirements
   

Once credentialed with Aetna, providers should focus on maintaining their status:

Quality Metrics

• Monitor patient satisfaction scores
• Track clinical outcomes
• Participate in quality improvement initiatives

Compliance Requirements

• Adhere to Aetna’s policies and procedures
• Maintain accurate billing practices
• Participate in required training or education

Communication

• Keep contact information current
• Promptly report any changes in practice status
• Maintain open lines of communication with Aetna representatives