All You Need to Know about Medical Provider Credentialing and Why Is it Important?


All You Need to Know about Medical Provider Credentialing and Why Is it Important?

When a health care provider is being credentialed, there are numerous stakeholders and moving pieces. Your doctor and other healthcare professionals must show that they possess the training, knowledge, and expertise required to provide patients with the best possible treatment. Healthcare oversight organizations simultaneously keep an eye on the activities of healthcare professionals and assess reports of, among other things, inappropriate care. Both the healthcare facility that employs the healthcare provider and the health insurance provider that plans to distribute the list of approved healthcare providers must regularly review these reports and monitoring.

The procedure of obtaining healthcare provider credentials is indeed laborious. This article explains the fundamentals of provider credentialing and includes suggestions for carrying out your duties as effectively and efficiently as possible in an effort to reduce some of that uncertainty.

What is Healthcare Provider Credentialing?

The process through which a healthcare provider confirms the credentials of health care professionals to make sure they have the required licenses, certificates, and skills to effectively care for patients is known as provider credentialing.

Other names for this procedure are medical credentialing, physician credentialing, and physician credentialing. The process of certifying physicians is the aspect of healthcare credentialing that is most frequently mentioned, although there are other similar (though occasionally less comprehensive) procedures in existence for nurses and other healthcare providers.

Organizations that regulate or provide standards for provider credentialing

Credentialing of healthcare providers is required by both the federal Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations; healthcare organizations that do not adhere to CMS requirements are not eligible for reimbursement from Medicare or Medicaid. Comparably, the Joint Commission only grants accreditation to those who abide by its requirements. The majority of hospitals in the US pursue Joint Commission certification, which is necessary to qualify for Medicare and Medicaid funding. Additionally, each state has its own laws.

Many healthcare organizations adhere to the requirements established by other parties for extra accreditation. These organizations include the Utilization Review and Accreditation Commission (URAC), the National Committee for Quality Assurance (NCQA), Det Norske Veritas (DNV), and the Accreditation Association for Ambulatory Healthcare (AAAHC).

How does Provider Credential work?  

Verifying a healthcare provider's credentials to ensure they are valid is known as provider credentialing. This entails contacting numerous agencies to confirm that the provider holds the necessary qualifications and credentials, including medical schools, licensing boards, and others. The credentialing body will also make sure there are no current issues that could indicate the practitioner lacks the skills necessary to treat patients effectively.

Key Phases for Provider Credentialing

The following are the three primary stages of provider credentialing:

1. Information gathering.

Providers are questioned about their past, credentials, and education by a healthcare organization or a health insurance group. Providers can email or use software to provide data in the form of a questionnaire.

An organization known as a Credentialing Verification Organization (CVO) works with the provider to gather and verify the data in some situations, and the healthcare institution or insurance provider may collaborate with it. CVOs are frequently hired by organizations to facilitate more effective credentialing.

2. Information verification

The facility or insurance provider will often do the background investigation. To confirm the practitioner's details, the facility or insurance provider will make direct contact with the licensing body, medical college, or other organization.

The CVO may carry out verification checks; the facility or insurance company may use the credentialing software to check the information that the licensing agency or other entity publishes online; or both the facility and the insurance company may use the credentialing software to check the information.

To organize and keep track of provider information and to get automated updates when particular credentials need to be renewed or updated, many healthcare organizations employ collaboration and work management platforms.

In both situations, checks entail keeping an eye on reports for medical errors, malpractice lawsuits, or other details that can cast doubt on whether or not practitioners can obtain new credentials.

3. Provide providers with credentials

After validating that the physician has all necessary credentials and that there are no red flags, the healthcare organization issues the credential.

A comparable procedure may be used by health insurance companies to determine whether to approve a provider as an in-network provider. In other words, the insurance provider will receive payment from the insurance company for treating patients who have insurance.

Information requested to Credential Healthcare Professional.  

First/Last Name







Mailing Address

Phone number



Education background




Work Experience

Hospital Affiliation

Facility/Location Address


Board Certification

Liability Insurance

Malpractice History etc.


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