What is provider credentialing or physician credentialing?

Provider credentialing is a regulated process of assessing the qualifications of specific types of providers. This important safety check requires providers such as doctors, dentists, and other allied healthcare professionals to show they have the proper education, training and licenses to care for patients. Hospitals and health plans verify the information supplied by the provider before they are included as an in-network provider.

The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) also require this credentialing process. CMS requires it before a provider can be eligible for Medicare or Medicaid reimbursement. And most hospitals pursue a Joint Commission accreditation to demonstrate their commitment to providing high-quality care.

How the provider credentialing process works

There are several steps in the provider enrollment and credentialing process. A provider has to complete this process with every health plan they want to enroll with.

1. The physician supplies the information required, including contact information, current CV, education and training history, licensing and certificates, medical group and hospital affiliations, Board certifications, sanctions or malpractice history, proof of liability insurance and peer references.
2. The health plan or provider organization checks that all the information is correct and up to date.
3. If no problems are encountered, the provider organization or health plan awards a credential to the provider.

The physician credentialing process can take as little as 30 days to complete up to as much as six months or more, particularly if the credentialing information is being transmitted via fax or mail.

Resources for health plans to speed up credentialing

Long credentialing processes cause significant financial challenges for health plans, hospitals, providers and patients. CAQH offers several solutions to streamline the provider credentialing process for health plans and providers.