PROVIDER CREDENTIALING OVERVIEW
Before a provider or organization can bill an insurance carrier, the provider must first be credentialed by the carrier. Credentialing is the process by which a health insurance carrier formally assesses a provider’s qualifications, and competency based on demonstrated competence. This can be a time-consuming process, and often takes up to six months to complete. The reason for the lengthy process is the requirement for submission of extensive background information. Depending on the circumstances, the clinic or organization for which the provider is working may also need to go through credentialing.
In the past, each provider had to be individually credentialed with each individual health insurance plan. For some, this is still the case. Many health insurance companies, however, are now using a centralized database. The Center for Affordable Quality Healthcare, Inc. (CAQH) is one of the most frequently used Web services for credentialing. CAQH offers an online database called the Universal Provider Datasource (UPD) that collects all of the information required for credentialing, and then makes it available to third-party payers.
To learn more about the UPD, see CAQH’s FAQ: http://www.caqh.org/updFAQ.php
In the event that the third-party payer does not utilize CAQH’s database you may have to provide the information directly. The following checklist is designed to help you manage the submission of the required background information.
Provider Credentialing Application
+ Checklist
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