Credentialing is an essential safety component of the healthcare system because the credentialing process verifies whether a physician is indeed qualified to practice.
Credentialing could also be considered the first step of the revenue cycle management process since insurance companies will only pay claims from credentialed physicians.
A credentialing application generally requires:
- Complete education history & transcripts
- Complete work history
- Current medical license, board certification, & DEA registration
- Up-to-date personal health history & immunization records
- Proof of continuous malpractice coverage
- Personal & professional references
- Thorough explanation of any gaps in history or other anomalies
And that’s just a partial list.
From the physician’s perspective, the credentialing process may seem strict and precise to the point of excess. Reviewers invariably check every reference, examine closely every declaration, and verify each element of the applicant’s history from the primary source. Even a single minor error or omission in a credentialing application can lead to prolonged delays. Given the sheer number & variety of components in a credentialing application, errors, delays, and administrative difficulties can seem all but inevitable.
What are the types of Credentialing in US Healthcare?
Provider credentialing falls into two main categories:
- Insurance credentialing
- Hospital credentialing
There is a fair amount of overlap between the two, but also some significant differences in terms of both purpose & the types of documentation required.
INSURANCE CREDENTIALING
The purpose of credentialing with insurance companies is to allow a provider to see patients with that particular insurance & then bill for services. If insurance credentialing is not completed, the physician will not be paid.
From a credentialing perspective, there are three main categories of insurance providers:
- Government payers
- CAQH payers
- Non-CAQH payers
Credentialing with each of these types of payers entails a somewhat different process.
Credentialing with government payers
Credentialing with Medicare & Medicaid is best done through the online Provider Enrollment, Chain, and Ownership System (PECOS). This is standardized throughout the country. State-based government payers each have their own credentialing process, though these are generally quite similar to the PECOS system.
Credentialing with CAQH payers
The Council for Affordable Quality Healthcare is a non-profit organization that establishes standards and provides tools to streamline the insurance credentialing process for commercial payers. Commercial insurance providers around the country use CAQH standards & tools as a core component of their credentialing process, though they may include supplemental segments of the application as well.
Credentialing with non-CAQH payers
While many of the largest health plans use CAQH standards, there are still many commercial payers that use CAQH tools & standards in a limited capacity, or not at all, in their credentialing process. Because these applications are not standardized, the provider & credentialing service must have all documents in order and address each non-CAQH payer’s credentialing process individually.
HOSPITAL CREDENTIALING
Credentialing with a particular hospital or hospital system allows a physician to see patients within that hospital. Physicians who are on staff at a hospital will address credentialing through their employer, and while not a simple process, staff physicians do have institutional support in their credentialing.

However, physicians seeking affiliate status at a particular hospital must navigate the credentialing process independently (also called Hospital affiliation), with minimal support from the hospital itself. Independent physicians usually must list one or more other physicians who may provide backup coverage for their patients. Naturally, these alternate physicians must already be credentialed at that hospital. A physician listed as a backup may also serve as a reference for the applicant.
Due to the need for backup coverage, networking and personal relationships are a major factor in hospital credentialing. Established physicians have a key role in accepting new physicians into a particular hospital or network.
In many cases, outside physicians actually encounter resistance from within the network, as established physicians may see them as competition. Navigating these relationships can be a challenge for new physicians.
What can derail the credentialing process?
One of the biggest challenges faced in credentialing is when applicants provide incomplete information. When the credentialing expert receives partial, incomplete, or missing information, it creates a lot of back and forth, which can be very time consuming.
Some organizations use credentialing software to help with this process by archiving information, so the provider only has to give it once regardless of how many times it’s needed for credentialing, privileging, or payer enrollment. However, the provider is still responsible for submitting complete information, and the credentialing expert is responsible for keeping it organized so the process can move forward.
The real value of your time
While credentialing in itself is an expense, the real cost of credentialing is in the time a physician is working – or not. A delay in credentialing can lead to a period of time not working, or not seeing patients with certain insurances. The cost of lost income from delays can easily be many times more than the cost of credentialing itself. This illustrates the importance of credentialing for every provider, practice, hospital and how big the role of credentialing companies and their responsibility are.