Why Anthem credentialing sucks in CA & NY and how to fix it

For healthcare providers in New York and California, credentialing with Anthem Blue Cross and Blue Shield can be a critical step to joining their network and serving patients effectively. However, many providers report difficulties, including unresponsive support and prolonged processing times, particularly when trying to address credentialing issues. This blog explores the challenges, offers practical solutions, and provides strategies to bypass or mitigate delays, ensuring providers can efficiently navigate Anthem’s credentialing process.

Common Issues with Anthem Credentialing

1. Unresponsive Support: Providers often struggle to reach Anthem’s credentialing team by phone or receive timely responses to inquiries.
2. Extended Delays: Applications can take far longer than the stated 45 days, with some providers waiting up to a year.
3. Application Errors or Deletions: Incomplete or outdated CAQH applications may be deleted, forcing providers to restart the process.
4. Carelon Integration: The transition to Carelon for behavioral health credentialing has introduced additional steps and confusion.

Anthem uses the Council for Affordable Quality Healthcare (CAQH) platform to streamline (streamline?) credentialing, which typically takes 45 days from the submission of a completed application. However, providers in New York and California have reported issues such as lack of direct communication, delays exceeding six months, and applications being stalled or deleted due to inactivity. The merger with Carelon Behavioral Health has further complicated the process for some, requiring additional submissions and causing frustration. These challenges can disrupt a provider’s ability to serve patients and receive timely reimbursements.

Solutions to Address Credentialing Challenges

Here are actionable steps to resolve or bypass these issues:

1. Optimize Your CAQH ProView Application

• Complete and Update Regularly: Ensure every section of your CAQH application is accurate, including licensure, education, and specialty documentation. Anthem requires a current CAQH profile, and incomplete applications can lead to delays or termination.
• Authorize Anthem Access: If registered with CAQH, explicitly authorize Anthem to access your information. Check your CAQH account to confirm authorization and attestation are up to date.
• Pro Tip: Review your application monthly to avoid expiration. If errors are found, correct them promptly via the CAQH portal or by emailing Anthem’s credentialing team at Credentialing@Anthem.com.

2. Escalate Through Official Channels

• File Formal Complaints: If you face persistent delays, contact Anthem’s official complaint department or Carelon’s provider services. Document all interactions, as emails are more effective than phone calls for tracking purposes.
• Engage State Authorities: In cases of extreme delays, file a complaint with your state’s insurance commissioner. Providers have reported progress after involving regulatory bodies, as this prompts Anthem to prioritize your case. For New York, contact the Department of Financial Services; for California, reach out to the Department of Managed Health Care.
• BBB Complaints: Filing a complaint with the Better Business Bureau can also push Anthem to address your application.

3. Consider a Credentialing Agency

• Hiring a professional credentialing service can streamline the process. These agencies specialize in navigating complex insurance requirements, communicating directly with Anthem or Carelon, and ensuring your application is complete. While this involves a cost, it can save time and reduce frustration, especially for providers facing prolonged delays.
• Choosing an Agency: Look for agencies with experience in New York and California healthcare markets and a track record with Anthem. Ensure they offer ongoing support for recredentialing, which Anthem requires every three years.

4. Leverage Provider Relations

• Contact your Anthem Provider Relations representative or call Provider Services (New York: 1-800-450-8753; California: check the Anthem Blue Cross provider portal for local numbers). These contacts can provide status updates or escalate your application.
• Persistence Pays Off: If initial outreach is unresponsive, follow up consistently via email and request escalation to senior management. Providers have noted that persistent follow-ups can prompt action.

5. Workaround: Out-of-Network Billing

• Temporary Solution: If credentialing delays prevent in-network participation, consider operating as an out-of-network provider. Payments for out-of-network services are typically sent to the member, but you can negotiate agreements with Anthem or leverage state mandates to receive direct payments. This approach ensures you can continue serving patients while awaiting credentialing approval.
• Patient Communication: Clearly inform patients about out-of-network status and potential costs. Provide guidance on submitting claims to Anthem for reimbursement.

By staying proactive and leveraging available resources, you can successfully navigate Anthem’s system and focus on delivering quality care to your patients.

Ready to share your experience or need further assistance? Connect with us and comment below to join the conversation and help other providers overcome Anthem credentialing hurdles!