What Is Physician Credentialing?

Written by Researchbite | Updated on: February 18, 2023

What Is Physician Credentialing?

Credentialing, also known as physician credentialing, healthcare credentialing, or insurance credentialing, is the procedure of acquiring, validating, and evaluating a medical practitioner's credentials to ensure they can deliver the necessary medical services.


Credentials are written proof of a medical practitioner's licensing, education, training, experience, or other credentials. Medical billing requires that the credentialing procedure be followed. Obtaining credentials enables healthcare professionals to sign up with the insurance firms they want to do business with. In addition, Credentialing ensures that doctors can give their patients the best treatment possible. Payers also utilize this credentialing data to assess whether doctors are qualified to treat their beneficiaries by their professional backgrounds. This procedure is required by most health insurance providers, including CMS/Medicare, Medicaid, and commercial plans, since practical credentialing help maintain high standards of safety in the medical industry.

What Exactly Is Physician Credentialing?

Physician credentialing, which is done in the healthcare industry, is the process of gathering and confirming a doctor's professional credentials. Their board certifications, hospital admitting rights, education, malpractice insurance, professional references, employment history, and other credentials are among them. It is a crucial protection for risk management and patient safety. Organizations must maintain a dossier on each provider and get primary source confirmation of the practitioner's education, training, credentials, and license. A doctor authorizes an organization and its credentialing staff to investigate their past, education, licensing, and professional qualifications when they apply for admitting privileges in a hospital or medical practice. They will utilize the operations and specialized tools in such procedures, and a physician must have the necessary credentials.

Businesses and Service Providers need to obtain Insurance Company Credentials

  • Increase patient assurance
  • Create professionalism in a medical environment
  • Get payment promptly and without delays
  • Prevent medical mistakes and deliver better care
  • Increase the patient pool
  • Accept new patients who have unique insurance schemes.

Organizations should conduct physician credentialing to confirm the integrity of the doctor's data on their application. The practice, hospital, or credentialing personnel will carry out primary source verification for some provider data, which necessitates getting in touch with the organizations or boards that granted the initial certification. For instance, a company may contact the doctor's medical school to confirm that they did attend and get the claimed medical degree. The Affordable Care Act significantly enhanced the physician credentialing standards for Medicare and Medicaid enrollment to combat fraud and abuse. Currently, the federal government, each state government, and each certification organization demand that physicians have credentials.

The credentialing procedure for physicians should be started as soon as feasible because it can take between 90 and 180 days. Each Payer has its internal schedule for processing applications. It may not be possible to expedite an application due to the size of some payer organizations.

The Process of Credentialing's Significant Elements

Insurance credentialing processes, where the Payer examines the physician's education, license, experience, certifications, affiliations, malpractice, adverse clinical events, and training, certify that a physician satisfies the criteria for providing clinical treatment. To get paid for the services provided to their customers enrolled in that insurance plan, clinicians or nursing staff must complete this process to be in network with certain insurance companies.

The significant steps in the procedure are:

Determine the pertinent documents

Each insurance company needs different forms and documents. The provider must apply with all the supporting materials required by the insurers; failing to do so might cause the approval process to be delayed by weeks or months. Name, SSN or Social Security number, demographic information, educational information, evidence of licensing, claims history, job history, and other facts are mostly needed.

Submit application forms

When the pertinent information is accessible, the next step is to rank the insurers by creating a list of all the insurance companies with which the practice intends to submit claims. Finally, complete the online or paper application forms and double-check and validate all the papers you've gathered. Any mistakes in the information given, such as inaccurate phone numbers or the wrong month or date of employment, might lead to problems.

Finish the CAQH profile

Several significant healthcare insurers require partner facilities to apply for credentialing with the Council for Affordable Quality Healthcare (while completing their applications). On paper or online, providers must complete the CAQH form. When necessary, re-attest the facts after submitting the first application.

Regular Follow-Ups

Clarify any issues that payers may have, follow up on any credentialing requests, and ensure that the application will be processed quickly. The physician credentialing procedure is drawn out and often takes 90 to 120 days.


Re-credentialing is the periodic evaluation and verification of professional qualifications following the credentialing requirements of payers. Application evaluation, credentials verification, and Regional Network and Credentialing Committee (RNCC) review are all possible steps in the re-credentialing process.

The Primary Challenges to Physician Credentialing

  • The main factor contributing to the processing backlog is incomplete applications. There can be inaccurate or missing information. Some data, including job history and current attestations, may need to be updated.
  •  The regulations governing credentialing vary from state to state. Healthcare practitioners are responsible for ensuring that they follow the laws of the state they work in. While reciprocity rules facilitate some simplification, it is still crucial to comprehend the variations in state legislation and have the credentialing process carried out correctly.
  • In some circumstances, it is still necessary for a doctor or medical facility to apply for separate credentialing with each insurance payer. They find it tiresome to carry out each procedure independently in such circumstances. Many coverage firms now perform credentialing using the confirmed inputs from the Council of Affordable Quality Healthcare, Inc. (CAQH), a collection of data relevant to credentialing. To ensure the database has the most recent data, the provider must update it to guarantee that the players are given accurate data.
  • As was noted in the situations necessitating credentialing, each practice or hospital a medical practitioner is affiliated with requires a different credential. Again, this might take a while. The qualifications of a doctor from one hospital are no longer required.

Engagement In The Credentialing Procedure

Physicians primarily communicate with the medical staff services office at the facility where they will be working throughout the credentialing process. When performing a locum tenens assignment, they will also collaborate with coordinators of hospital privileges.

  • Depending on the size of the facility, the following individuals may be engaged after the facility sends your proposal to the approval process:
  • Departmental heads
  • Members of the credentialing committee, such as facilities managers, human resources specialists, and risk management experts
  • Members of the executive medical committee
  • The governing body or CEO

The application approval procedure can often take a long time since each committee or board has separate meetings to consider each application.

Quick Guidelines for Physician Credentialing

These stages should be included in your organization's procedure to expedite physician credentialing.

  1. Be sure to begin the procedure. Plan for 120 to 150 days to finish all certifications as soon as you know you're bringing a new doctor on board.
  2. Use technology when appropriate to simplify and decrease mistakes in the credentialing process.
  3. A set of strict deadlines associated with the medical credentialing process can guarantee that it moves forward when a new physician enters a practice.
  4. Make sure a doctor's Curriculum Vitae (CV) is current. Confusion will be avoided.
  5. All required supplementary materials should be available online.
  6. State laws governing medical credentialing differ, and new legislation may have an influence. To avoid unpleasant surprises along the way, it's critical to periodically review for updates and modifications and adapt internal procedures accordingly.

The Purpose Of Physicians' Credentialing

The process of physician certification has several uses. By confirming that all physicians are practicing at the same level of care and rendering the clinical services for which they are licensed, credentialing provides the medical business with quality assurance. Limiting access to only physicians qualified to work on patients with insurance safeguards not just the patient's safety but also the health of the medical profession. Medical credentialing also enables medical practices to obtain timely and accurate payments from the third parties they have negotiated. In addition, reasonable medical practices can increase the number of people who can access them, increasing their income streams. Medical credentialing is crucial for the success of medical practices since it facilitates more accessible payment options and access to larger patient populations.


The ability and credibility credentialing of a physician, surgeon, nurse, lab technician, or even a therapist to execute healthcare activities competently must be determined by their medical credentials. The process of privileging or providing authorization to carry out medical, surgical, psychiatric, or other patient care services follows the verification of credentials. The credentialing and privileging processes take a lot of time, effort, and attention to detail since a medical practice must first obtain the necessary data before screening candidates based on their qualifications. While the applicant must be truthful while completing and submitting the application, it is still the medical organization's responsibility to check all the applicant's credentials.


  • https://education.ncgmedical.com/blog/advantages-medical-credentialing
  • https://comphealth.com/resources/understanding-the-credentialing-process



Written by
ResearchBite is a platform committed to availing the scientific knowledge and information at your fingertips.

Check out other articles written by Researchbite .