Healthcare credentialing is the process by which medical organizations verify the credentials of healthcare providers to ensure they have the required licenses, certifications, and skills to properly care for patients. Most facilities need to ensure their healthcare providers have proper credentials in order to process insurance claims. Even if some of your clients are uninsured or pay out-of-pocket, credentialing is important for providing broad access to care.
From a financial perspective, organizations typically cannot obtain reimbursement for provided services from insurance entities including Medicaid/Medicare if they lack medical credentialing. As you begin the credentialing process in healthcare, be aware that each insurer requires different documentation and forms. You’ll need to submit complete applications to each insurer you plan to work with—and even a single missing piece of information can delay approval by weeks or months. Several major healthcare insurers require partner facilities to apply for credentialing through the Council for Affordable Quality Healthcare (while also completing their individual applications)
Once you’ve assembled and submitted your application to insurers, it’s time to wait for their approval. This can be a lengthy process. If you discover an error in an employee’s information, it’s important to notify insurers. If they notice the erroneous information before you submit a formal correction, it could be grounds for revocation.
Most providers need re-credentialing every three years.