Credentialing

Key facts

Hospital requirement

Medicare Conditions of Participation, 42 CFR 482.22 (medical staff)

Health plan standards

Commonly NCQA standards, with recredentialing at least every 36 months

Required hospital query

National Practitioner Data Bank, at appointment and every 2 years

Verification method

Primary source verification with the issuing organization

What is credentialing?

Credentialing answers a basic question: is this clinician who they claim to be, and are they qualified? The organization collects the clinician's information and confirms it with the original source, such as the state licensing board, medical school, residency program or certifying board, rather than relying on copies.

Credentialing repeats on a cycle, called recredentialing or reappointment, so organizations catch expired licenses, new sanctions and malpractice claims that arose after the first review.

What credentialing checks

A typical credentialing file covers:

• State licenses and any disciplinary actions.
• Medical education, residency and fellowship training.
• Board certification status.
• DEA registration and any state controlled substance registrations.
• Work history, malpractice claims history and professional liability insurance.
• Reports in the National Practitioner Data Bank and exclusions from federal health programs, such as the HHS Office of Inspector General exclusion list.

Credentialing vs privileging vs enrollment

These steps are often confused. Credentialing verifies qualifications. Privileging, done by hospitals, grants permission to perform specific services at that facility based on those credentials. Payer enrollment and contracting then allow the clinician to bill a particular health plan, and Medicare enrollment happens separately through PECOS. A clinician can be fully credentialed at a hospital and still be unable to bill a given insurer.

Why credentialing matters

Credentialing can take weeks to months, so it sets how quickly a new clinician can see patients and generate revenue, a key issue for physician recruiters, locum tenens staffing and practice acquisitions. Health plans rely on it for network quality, and errors in credentialing data can carry over into provider directories.

Credentialing failures also carry legal and financial risk. Hospitals can face negligent credentialing claims when they grant privileges to a clinician they should have screened out, and organizations that bill federal health programs for services by excluded individuals can face repayment demands and civil monetary penalties.