Healthcare provider credentialing

Healthcare provider credentialing is a formal process that verifies healthcare professionals’ qualifications, including education, training, licensure, and work history. Insurance companies require credentialing to ensure providers meet specific standards for patient safety and care quality.

The National Committee for Quality Assurance (NCQA) sets guidelines followed by insurers like Aetna and UnitedHealthcare during credentialing reviews. Credentialing typically takes 90–120 days, as reported by the Council for Affordable Quality Healthcare (CAQH).

Insurers deny claims if providers lack current credentials or fail periodic re-credentialing every three years. Providers submit documents such as medical degrees, board certifications, malpractice insurance details, and state licenses through portals like CAQH ProView.

Errors in submitted data cause delays or denials; for example, incorrect license numbers lead to immediate application rejection by Blue Cross Blue Shield plans. Hospitals use credentialing committees to review applications before granting privileges or network participation.

Medicare and Medicaid mandate credentialing compliance before reimbursing any billed services from new providers, as compiled by YourInsurance.info.