Credentialing Process

What is Credentialing:

Credentialing is a systematic approach to the collection and verification of a health care provider’s professional qualifications. The qualifications that are reviewed and verified include, but are not limited to, relevant training, licensure, certification and/or registration to practice in a healthcare field, and academic background. – Insurance credentialing is the process of becoming affiliated with insurance companies to ensure health care providers can accept third party reimbursement. – A credentialing process is utilized by health care facilities as part of its process to allow practitioners to provide services on its campus, health plans to allow providers to participate in its network (provider enrollment), and other health care entities that have a need to hire or otherwise engage providers. – Privileging is the granting of permission to practice in an institution within the framework of defined clinical practice.

What is Provider Enrollment:

Provider enrollment refers to the process of requesting participation in a health insurance network as a participating provider.

 The provider enrollment process involves requesting enrollment/contracting with a plan; completing the plan’s credentialing/enrollment application; submitting copies of licenses, insurance, and other documents; signing a contract; and any other steps that may be unique to a carrier. Many commercial carriers utilize the Council for Affordable Quality Healthcare (CAQH) to obtain credentialing information from a central location and require that providers have a complete and up-to-date profile in the CAQH system as part of the enrollment process.

What is CAQH:

Nonprofit alliance of healthcare organizations, including insurers, health systems, health maintenance organizations (HMOs), and third party administrators (TPAs). – In 2002, CAQH initiated Universal Provider Datasource (UPD) , a fully electronic solution that saves time and resources. It simplifies and expedites provider data collection and self-reporting of provider information for payors, hospitals, large provider groups, and health systems. CAQH is supported by all major insurance and provider associations.

CAQH is the leading, industry-wide service to address one of health care providers’ most redundant administrative tasks: the credentialing application process. – Under the CAQH program, health care providers use a standard application and a common database to submit one application to one source to meet the needs of all of the health plans and hospitals participating in the CAQH effort.

What is being Contracted and Credentialed:

A Contract is an agreement having a lawful object entered voluntarily by two or more parties, each of whom intends to create one or more legal obligations between them. A provider Contract is one in which the provider agrees to the terms and conditions of the health plan/insurer in order to be accepted as an In-Network Provider of said health plan/insurer.

Credentialing includes contracting application agreement in addition to liability protection for the health plans constituents; includes providing full background of professional work and liability history, education, state regulatory requirements, citizenship, etc. The health plan/insurer is verifying to their members that the contracted professional has met the requirements of licensure, expertise, professional history, and liability. – Credentialing is an extra step above the contracting process, providing liability protection for both the insurer and the insured.

The Process for Medical Practices:

Healthcare practices, such as the Student Health Care Center, clinic, practice or hospital are vetted and approved as credentialed healthcare payors just as the medical practitioners. During the credentialing process the payor will request that the medical practitioners agree to certain conditions of payment in the event that the medical provider is approved. These requests are usually pursuant to general terms of the insurance policy for the patients for which they are providing services.

An important note to keep in mind is that once the credentialing process is complete, there does not exist a requirement to accept the terms and conditions of the insurance company. The final terms and conditions under which the medical practitioners will perform services are subject to change and negotiations.

In the event that no agreement can be reached, the credentialing process does not require the Student Healthcare Center to submit and agree to submit claims to the medical insurance company.

Once credentialing is completed by the University’s representatives, the University or practice  may request that a specific payor makes changes or modifications to the policy conditions for the payment of medical services. In the event that such requests cannot be met the University or practice may choose to not directly bill such payors for medical services provided. Instead, the University or practice may bill the patient for such provided services and the patient can then seek reimbursement under their specific policy.

What is Provider Enrollment:

All three, PECOS, NPPES and I&A are electronic portals used by Medicare and/or Medicaid in managing provider data for their approved providers.

The following are the definitions and where they are applied:


Provider Enrollment Chain and Ownership System. This is primarily an online Medicare system.


National Plan and Provider Enumeration System center are for Medicare and Medicaid managed provider information and their identifiers.


 Identity and Access Management. This portal is for authorized officials and their staff to manage online data for both PECOS and NPPES.

The above three access systems require completion and consent by the providers to be considered as providers under Medicare and Medicaid. Please recall that certain third party payors use Medicare and Medicaid as benchmarks in their credentialing process.

Again, in the event that providers are ultimately credentialled under Medicare and Medicaid and the providers and/or the University or practice find a component of the Medicare and Medicaid agreements to be unacceptable, the University or practice and its providers may elect to not bill nor accept payments from the Medicare and Medicaid and address the fees for services covered by those plans directly with the patients.