The basics of provider credentialing:

Initial Application

The Credentialing department reviews your applications within 45-60 days of receiving a fully completed application. If additional information is needed, the payers will respond within 2-3 weeks. Applicants are notified within that period if credentialing has been approved or if additional time is needed. The payers contact applicants to obtain any missing documentation. Once the initial application and all applicable verifications are completed, the credentialing department, considers all information gathered on the provider and evaluates the provider based on payer-specific credentialing criteria. The credentialing department decides to approve or deny the provider’s application. The provider is then informed of their decision. Providers are generally credentialed for a three-year period. However, the credentialing department may recommend credentialing for a shorter period based on the results of its review. If so, the provider is advised of the decision and the reason for the shorter approval period.

CAQH ProView

Insurance carrier validates the accuracy of a provider’s service location data during both credentialing and re-credentialing by reviewing the provider’s data in CAQH ProView® and performing telephone outreach. Payers require all applicants for all networks to complete the Council for Affordable Quality Healthcare (CAQH) ProView® credentialing application form. If you do not have a CAQH number, register with CAQH ProView.

Getting Credentialed

The credentialing department performs the initial approval and credentialing of providers and facilities for participation with payer networks. The credentialing department will review and verify the completeness of every provider’s application. This includes primary source verification of the provider’s licensure and accreditation. The Centers for Medicare & Medicaid Services (CMS) requires primary source verification of education and training records and board certification. The credentialing department reassesses providers and organizational providers every three years (at minimum) to assure all credentialed providers and organizations remain qualified and continue to meet payers’ criteria for participation.

When contracting with New York State (NYS)-designated providers, payers will not separately credential individual staff members in their capacity as employees of these programs. Payers will still conduct program integrity reviews to ensure provider staff is not disbarred from Medicaid or in any other way excluded from Medicaid reimbursement. Payers will still collect and accept program integrity-related information from these providers, as required in the Medicaid Managed Care Model Contract. This means they require such providers to not employ or contract with any employee, subcontractor, or agent who has been debarred or suspended by the federal or state government or otherwise excluded from participation in the Medicare or Medicaid program.

Qualification Requirements

Every commercial insurance carrier has unique qualification requirements. For reference we shared some standard qualification requirements: 

• A valid, unencumbered license to practice
• Board Certification in practice specialty within 5 years of completion of training
• Current malpractice insurance coverage within acceptable limits
• Acceptable malpractice history
• Regulatory program participation status

Provider Re-credentialing

On average commercial insurance carrier requires all providers to undergo re-credentialing every three years. Providers must maintain the same minimum qualification requirements as applicable for the initial credentialing. The re-credentialing process evaluates each practitioner on the evaluation parameters like access and availability; quality of care; primary and secondary prevention; disease management; member satisfaction; medical record audit scores; member concerns; peer review; and continuity of care.

Generally, six (6) months prior to the expiration of credentials, providers receive a letter from the credentialing department for re-credentialing. In this communication, providers are requested to update their CAQH ProView® application with some of the documents:

• Malpractice claims history (if applicable)
• Updated copies of their curriculum vitae, state license, and Drug Enforcement Administration (DEA) certification
• Proof of malpractice insurance coverage

Providers with a complete application on file with CAQH ProView® can communicate with the payer to retrieve all documentation from this source. To ensure credentialing status with payers, it is important to update all re-credentialing materials as soon as possible. Failure to respond in a timely manner could result in termination from providers’ networks.