What is the Credentialing Process?

Credentialing is the process of verifying a provider’s qualifications (e.g. education, licenses, certifications, work history, references) and conducting a background check (financial, criminal, and/or social media history).

 

Credentialing involves two main objectives: Privileging and Enrollment.

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Privileging

Hospitals are responsible for granting privileges to their providers.

The hospital’s credentialing committee, executive committee, and board of directors all review the providers’ credentials. If approved, the provider’s initial appointment with the hospital is usually for one year. After that, renewal of appointment is generally for two years.

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Enrollment with Commercial
Health Plans

Provider enrollment/payor enrollment consists of 2 steps for commercial payers: credentialing and contracting

1. Credentialing

To submit a request to participate in the plan, the provider must follow the plan’s application process. The payor may use CAQH, a standardized state application, or its own unique application.
 

After receiving a provider’s application, the payor verifies the provider’s credentials, through Primary Source Verification (from the original source), according to its credentialing requirements. Then, the plan’s Credentialing Committee approves or rejects the applicant.
 

The credentialing step may take up to 90-150 days.

2. Contracting

After approval from the Credentialing Committee, the payor offers the provider a contract for participation. The provider reviews the reimbursement rates, provider responsibilities, and other details outlined in the contract’s language. If applicable, the provider may negotiate rates.
 

Once the provider signs and returns the contract to the payor, the provider receives a provider number and effective date and can start billing the plan for in-network reimbursement on claims.
 

The contracting step may take 60-90 days.
 

Keep in mind that these steps must be performed for EACH insurance plan in which the provider wishes to participate.

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Enrollment with Government
Health Plans

There are standard forms for government programs such as Medicare and Medicaid. The provider completes these forms and sends them to the intermediary that handles paperwork for the program in the provider’s specific jurisdiction.

Medicare enrollment is very detailed and entails strict standards and requirements. More information can be found at the CMS.gov website, including a list of CMS forms.

The Credentialing Life Cycle

The credentialing process does not end after providers are initially credentialed with hospitals and health plans.

 

Providers must renew their appointments with hospitals and continue to monitor their compliance with government and commercial payors throughout their careers. This includes updating certificates and licenses, meeting continuing education requirements, re-credentialing for commercial payors, and re-validation for Medicare and Medicaid.