Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy. Many health care institutions and provider networks conduct their own credentialing, generally through a credentialing specialist or electronic service, with review by a credentialing committee. It may include granting and reviewing specific clinical privileges, and allied health staff membership.
Physicians and other healthcare practitioners who wish to bill an insurance company and receive reimbursement for services as an in-network provider must undergo a process of credentialing. This process, otherwise known as primary source verification, is the process in which an insurance company verifies the provider's education, training, experience, and competency. In order to start this process, the provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty. Once the verifications are complete, the insurance company then decides if the provider meets their internal qualifications to serve as a provider of services to their insured members. After approval of a provider's credentialing file, the insurance company then issues a participating provider contract that allows the provider of services to bill the insurance company and receive reimbursement as an in-network provider of services. Failure to complete the insurance credentialing process will result in the provider being paid as out-of-network for services rendered
Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment). Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.
Political parties credential delegates at their conventions.
Paperless credentialing is the process of doing credentialing through a software package. With the internet, many web-based programs have been created to help automate the process of paperless credentialing.
Medical Credentialing is used interchangeably to refer to insurance credentialing or provider enrollment. Medical credentialing includes the primary source verification process at the payer or facility and the insurance contracting. Medical credentialing is utilized by healthcare practitioners when they desire to participate with an insurance company such as UnitedHealthcare or Medicare. The only difference with plans governed by CMS (Medicare & Medicaid) is that the government plans have set fee schedules and therefore do not need to contract directly with the practitioner or practice.