Provider credentialing

Physician credentialing is the process by which insurance networks, healthcare organizations, and hospitals obtain and evaluate documentation regarding a medical provider’s education, training, work history, licensure, regulatory compliance record, and malpractice history before allowing that provider to participate in a network or treat patients at a hospital or medical facility.

Once the verifications are complete, the insurance company then decides if the provider meets their internal qualifications to serve as a provider of services to their insured members. After approval of a provider’s credentialing file, the insurance company then issues a participating provider contract that allows the provider of services to bill the insurance company and receive reimbursement as an in-network provider of services. Failure to complete the insurance credentialing process will result in the provider being paid as out-of-network for services rendered.

 Some of the important credentialing check lists are:

•         NPI
•         Active State license
•         Professional Liability Insurance
•         Board Certifications and other eligible certification documents
•         Curriculum Vitae
•         Practice tax id, name, address, appointment phone and fax numbers

 CAQH is one of the most frequently used web services for credentialing. CAQH offers an online database that collects all of the information required for credentialing, and then makes it available to third-party payers.