Hospitals‎ · November 5, 2021

10 Things to Know About Provider Credentialing


Healthcare provider credentialing is the process that medical organizations use to verify medical professionals’ qualifications and licenses. It also ensures that they have the skills and experience to care for patients properly. However, credentialing is mainly used for doctors, ophthalmologists, podiatrists, and optometrists. Medical Credentialing is also in place for nurses and other types of healthcare providers.

A healthcare provider is not permitted to work until the physician credentialing process has been completed and approved. This protocol is in place to protect patients by ensuring that they will get care from healthcare professionals who are appropriately educated, trained, and licensed. If you begin practicing medicine before you are credentialed, you are putting yourself and your medical facility at legal risk.

10 most important things about medical credentialing

How Credentialing Works

The purpose of credentialing is to establish that you have the proper training and qualifications to treat your patients safely. The process requires that you contact several different organizations, such as the medical schools you attended, your licensing boards, and other certifying agencies, to verify that you and your physician team have the correct licenses and certificates. Credentialing also ensures that you have no past reported issues that could affect your ability to treat patients.

Regulating Bodies for Physician Credentialing

The Joint Commission requires healthcare provider credentialing on Accreditation of Healthcare Organizations and the Centers for Medicare & Medicaid Services (CMS). If you fail to follow the CMS mandates, you will not be eligible for reimbursement from Medicaid or Medicare. States also have their regulations.

What you Need to Submit with Your Application

When you submit your application for provider credentialing, you need to provide a range of important information. If you don’t include all the required data, this could delay your application significantly. Along with your application, you will need to submit:

● Proof of your education and training

● Acquired qualifications

● Details of your medical residency

● All your current licenses

● Any special certifications

● Your career history

The Credentialing Timeline

The credentialing process can take up to four months to complete. To avoid any unnecessary delay, you should start the process as early as possible – ideally four months before you are due to begin practicing medicine.

What you Need to Know About Re-credentialing

Whether you work in a hospital or clinic, you will be required to undergo the credentialing process regularly to remain in-network with the insurance companies as a healthcare provider. Typically, you will receive a letter to let you know when you are due to renew your credentials. To avoid suspension, you should complete the credentialing process as soon as possible before the deadline.

The Council for Affordable Quality Healthcare

The CAQH is a not-for-profit organization of many of America’s largest health insurance providers. It uses the Proview online database to collect and collate information from health care providers, such as their professional qualifications. Hundreds of insurance companies use the data to provide credentials to medical professionals. This saves you time because you don’t have to submit the same information to every insurance company you are enrolling with.

Completing the CAQH Application

While you can complete your CAQH on paper, the best way is online. Submitting online can save time and prevent delays because sometimes, CAQH has a backlog, which can delay them inputting your information in their system, delaying your credentialing.

Even when you complete it online, you should be mindful of other common errors that can delay the process. For example, you should make sure that your resume is complete and up to date. As you are inputting your information, make sure that you format it as requested. Don’t leave any gaps in your resume, or CAQH will suspend your application. Prepare scanned copies of the required information to have all the documents on hand when filling out your application. Re-attest your information every quarter. This is a simple procedure that confirms everything in your profile is still accurate. If you don’t re-attest, you run the risk of delaying your credentialing.

Familiarize yourself with your State’s Regulations

Some certification and licensing laws vary from state to state, and this can affect your physician credentialing. Each state’s medical licensing board does its own credentialing before approving a state license to practice. It’s important to note that your state may also have reciprocity agreements relating to payer and other credentialing within the state.

Common Causes for Credentialing Delays

The following list reveals the most common causes for delays in medical credentialing across the board:

● Incomplete or lapsed work history

● Insufficient proof of coverage

● Incomplete malpractice history

● Fewer than three references

● Uncovered hospital privileges

● Expired information in the credentialing database

The Advantages of Credentialing Service

There are numerous benefits to outsourcing physician credentialing, including:

● Get experts to do the job for you so that you can focus on your practice.

● Eliminating application errors, so you don’t have to worry about delays.

● Reducing operating costs so you can keep your cash flowing.

● Saving you lots of hassle and hours of paperwork.

● Allowing your practice staff to focus on their daily duties.


The growing number of Covid-19 cases and the increasing number of challenges have made it difficult for healthcare facilities to rely on traditional methods and administrators for medical credentialing. The solution for medical practices or clinics is to partner with an established and leading company that provides credentialing services.

It’s essential to get credentialing right the first time and to keep it up to date. Credentialing issues can be costly and can reduce your productivity level. It is, therefore, crucial to have a process in place to keep things running smoothly.

There are a number of leading healthcare credentialing service providers, who can help you verify your medical credentials with the minimum of hassle. Find out more about provider credentialing while focusing on your patients.

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