Most common questions

What is provider credentialing?

Provider credentialing is often referred to as Primary Source Verification. The process is used by hospitals, health plans, and other facilities to verify the credentials of a particular physician or provider (also see What documents are required for provider credentialing? under FAQs list). You may also hear provider credentialing referenced interchangeably as insurance enrollment. Although we do not provide primary source verification services (i.e., verification of credentials), we do enroll providers with insurance plans across the country. Whether it’s enrollment in Medicare, Medicaid, various commercial insurance plans, or even the various worker compensation networks, our team of credentialing specialists have decades of experience to ensure the expert care and attention your practice deserves.

How long will my credentialing take?

Well, to be honest, it depends—there’s not a single answer. For example, the length of time it takes to credential is:

  • Usually shorter if a physician or provider is already enrolled in a health plan (i.e., insurance coverage). But it takes longer for a provider who has never completed credentialing with an insurance company.
  • Usually shorter if the provider is already affiliated with a practice group’s tax ID. But it takes longer for a new provider who must first be contracted with a practice group’s tax ID before linking the provider to the group’s health plan.
  • Usually shorter if your existing practice group already has a provider contract in place. In this case we don’t need to complete the provider’s initial contracting process with the practice group. But it takes some time to credential new providers and link them to your established group.
  • With all of this being said, the time frames vary between 60 to 180 days depending on your unique scenario. This is why our CEO likes to have phone discussions with all potential clients to set realistic expectations regarding the anticipated time frame.

What is a CAQH?

CAQH stands for Council for Affordable Quality Healthcare. It’s essentially an online database account that stores provider information. Providers typically grant access to their information to insurance companies.

An overview of CAQH includes the following benefits:

  • Of all the national health insurance companies, 90% use CAQH as a prerequisite for their enrollment process.
  • The CAQH centralized database with required authorization is considered an industry-wide standard that supports a more efficient credentialing process.
  • Instead of calling your office for the provider’s work history or copy of a medical license, insurance companies can pull it directly from your CAQH file.
  • CAQH Credentialing process:

    • Obtain your CAQH ID (within 2-3 business days)
    • Set up your secure username and password
    • Complete the online application and send in required documentation
    • Send your attestation for signature which certifies the application
    • Grant insurance companies access to your online application
    • You are now ready to start the credentialing/contracting process with the insurers

What documents are required for credentialing?

Individual provider documents:

  1. State Medical License
  2. Certificate of Malpractice Insurance (COI)
  3. Federal DEA License
  4. State DEA License (CDS License; if required by state)
  5. Board Certification(s)
  6. Current CV (use MM/YYYY format; show current employer)
  7. Driver's License
  8. Diploma (highest level of education)
  9. ECFMG Certificate (for providers educated outside the United States; Educational Commission for Foreign Medical Graduates)
  10. Collaborative Agreement (required for Nurse Practitioners only)
  11. Prescribing Arrangement Letter (for providers not holding federal DEA License)
  12. Admitting Arrangement Letter (for providers who do not have active hospital admitting privileges)

Legal entity documents (copies only for license and certificate requirements):

  1. State Business License
  2. Certificate of Malpractice Insurance (COI)
  3. CLIA Certificate (if applicable; Clinical Laboratory Improvement Amendments of 1988)
  4. IRS W-9 Form
  5. IRS Form CP575 or replacement letter 147C (verification of EIN/TIN)
  6. Bank Account Verification Letter