In today’s fast-paced healthcare environment, being qualified and getting degrees isn’t just enough. Healthcare providers also need to be credentialed. Credentialing means the medical provider is also qualified to provide care. It is a complex process that you have to go through to apply for a job. It includes their qualification, training, license, and work ethic.
It is the background check of the healthcare provider. You have to prove your competence, earn patient trust, and ensure that you provide top-class care better than anyone. Credentialing is the process by which the company checks if you are an authentic person and compatible for the job, or if you are just a fraud pretending to be someone you are not.
Whether you’re starting a new clinic or working in a large multi-specialty group, credentialing is the gateway to participation in hospital affiliations, insurance networks, and even telehealth platforms.
We will break down the credentialing services step-by-step; it will help you avoid delays along the way.
Credentialing Services Step-by-Step Process
Credentialing may feel like a complicated task, especially for new providers. However, it gets easier if you break it into steps and manage it. The steps are as follows:
- Initial preparation
- Submitting the credentialing application
- Primary source verification
- Addressing application deficits
- Dealing with payer timelines
- Utilizing CAQH
- Staying compliant with state laws
- Insurance contracting
- Telemedicine credentialing
- Ongoing maintenance
1. Initial Preparation
Preparation is half the battle. Make your foundation strong and take all the time to gather the essential documents and information that you might need to avoid delays and less back-and-forth.
Obtain Your NPI Number
If you don’t have an NPI, the very first thing you should do is to apply for your national provider identifier through the website of your country. This 10-digit number is required for your identification across systems.
Secure Malpractice Insurance
Many hospitals and companies demand proof of active professional liability coverage. So, make sure that your policy meets minimum coverage requirements.
Update Your CV or Resume
Make a professional CV. Ensure the information included is current and accurate. It should include education training with years and dates. Work history, if applicable, and medical licenses and certificates. All data should be up-to-date and accurate without exaggeration. Renew things that have expired.
Collect education and training and gap documents.
Collect and manage all your documents in one place, like diplomas, board certificates, and transcripts. All the work experience documents should also be included in it. Most payers require written clarification for any gaps of over 30 to 60 days. Be ready to explain everything.
Create or Update Your CAQH Profile
Make your CAQH ProView account and update your data there if you already have one. Many payers obtain their required information directly from your profile. Make your profile set to ‘available to all payers.’ You have to upload relevant documents and keep your profile updated.
2. Submitting the Credentialing Application
When you are done completing your documents, the next step is to submit the credential application to hospitals and healthcare companies, and insurance payers. Most insurers have their online portals where you have to upload all of the required information. You have to be accurate; even minor mistakes can cause costly delays. You’ll be asked to include:
- Personal and professional information
- Education and training history
- Malpractice claims history
- Hospital connections
- References
3. Primary Source Verification
After submitting your application, the next step the payer asks for is primary source verification of the healthcare provider. It is the process of verifying the healthcare provider’s credentials by directly contacting the organization or source. It is the key step in the credentialing process. It is the way of checking whether the information provided is correct. It is required by many hospitals and companies. This is often the longest process in the credentialing process, and it can take up to 60–120 days, depending on responsiveness from other parties.
For example, they will:
- Contact your medical school to verify graduation
- Confirm your residency or fellowship completion.
- Check licensure status with state boards.
- Review malpractice history with the National Practitioner Data Bank (NPDB)
- Validate your DEA registration.
4. Addressing Application Deficits
Many applications are delayed or rejected due to outdated documents, missing information, or inconsistencies in your professional history and uploaded information details. Be proactive. Regularly follow up with payers’ requirements and verify that they have all the needed documentation accurately. If there are issues, make up for your mistakes with a given explanation.
Common irregularities include:
- Gaps not explained in education and training
- Inaccurate contact information
- Expired or soon-to-expire licenses
- Incomplete peer references
- Unreported malpractice claims
- Missing proper details
5. Dealing with Payer Timelines
One of the most frustrating parts of the credentialing process is waiting for the payers to review the information. After submitting a complete and accurate application from your end, it can take up to 60-180 days to receive approval. It can take more days than this, depending on company policy. Payers conduct a thorough investigation before stamping the applications. It is a more complicated thing than you think. Each insurance company has its own policies to review the applications, and to avoid delays, you just have to give accurate information according to their demand. In some cases, “expedited credentialing” may be an option, especially if you’re part of a large group or filling a provider shortage in the area.
What you can do:
- Submit applications at least 3–6 months before your desired start date
- Follow up regularly; don’t wait for a response.
- Keep records of all submissions
- Use a spreadsheet or software to track status across different payers.
6. Utilizing CAQH for Credentialing
CAQH stands for the Council for Affordable Quality Healthcare. It is basically an online database where you can upload all of your information and details, and the companies and payers can access it for credentialing. You can make your profile free of cost. Most companies demand CAQH profiles to verify and access your data. It is a universal credentialing hub that saves you from filling out the same forms for insurance companies; you just share your profile, and you are on the go.
Most major insurance companies, including Aetna, Cigna, UnitedHealthcare, and many Blues plans, demand a complete and attested CAQH profile for credentialing. Keeping your CAQH profile updated is overwhelming. An outdated profile can stall multiple credentialing applications at once.
How to make CAQH:
- Create a CAQH profile
- Fill in all professional and personal details accurately.
- Upload supporting documents
- Attest to your information every 120 days.
7. Staying Updated with State Laws
Credentialing is not a simple process; you have to stay updated with state laws to avoid delays and denials. What works for one state might not work for another. For example, each US state has its own rules, requirements, and timelines for health care credentialing. It’s better to stay informed about your state’s laws. And not just in the initial process, but you have to stay updated for your ongoing practice if they conduct recredentialing. If you fail to meet the requirements, it can lead to denials, delays, or sometimes legal penalties. To avoid these things, partner with a credentialing expert who is familiar with state laws and requirements.
What to watch for:
- Delegated credentialing for group practices
- Background checks or fingerprinting.
- Timelines for approval may be governed by state law.
- Medicaid enrollment rules differ from state to state.
8. Insurance Contracting
After completing credentialing and approval, the next crucial step is insurance credentialing. It is the process of reviewing the final agreement with a health plan to become their in-network provider. This agreement includes how you will work, what services you will provide, and how much you will be paid for your services. Contracting basically means you get paid for your work. Before signing a contract or agreement, thoroughly study all the terms carefully. This agreement is going to be how you will work with the company, and you cannot change it again and again. So, if needed, negotiate better rates with the company. The agreement includes:
- Reimbursement rates
- Covered services
- Claims submission procedures
- Credentialing renewal periods
9. Telemedicine Credentialing
It is the process of verifying the healthcare provider’s qualifications, credentials, and licensure. If you are applying for telehealth platforms, then telemedicine credentialing is very important. It is their way of verifying the company if you can provide virtual care as good as you provide in-person care. The company cannot accept your job without full satisfaction that you can deliver the required services perfectly. You have to prepare yourself for giving virtual services; make sure you’re clear so that the company will be satisfied with you.
- You must be licensed in the patient’s state according to their requirements.
- Credentialing must be done for each state where services are offered by the healthcare provider.
- Payers may require additional documentation for telehealth services. Make sure to give them all
10. Ongoing Maintenance
If you think credentialing is a one-time process, you are wrong. It is an ongoing process. Many companies conduct recredentialing after a year or 2. Which means you have to keep your data or profile updated to avoid cancellation of your application after recredentialing. Missing its deadline can lead to deactivation from the payer network, which can cause disturbance in patient care, and your payment can also be affected. You just can’t sit after passing one-time credentialing; you have to keep updating your following details:
- Keep licenses, certifications, and insurance active
- Update CAQH and payer profiles regularly.
- Respond to recredentialing requests promptly.
- Track expiration dates and renewal deadlines
Who Needs Credentialing?
Credentialing isn’t just for doctors. It applies to a wide range of healthcare professionals who provide billable services or require hospital privileges. If you’re billing insurance or working in a facility that mandates credentialing, you’ll need to go through the process.
This includes:
- Physicians (MDs, DOs)
- Nurse practitioners (NPs)
- Physician assistants (PAs)
- Psychologists and counselors
- Physical and occupational therapists
- Dentists and oral surgeons
- Clinical social workers
Documents Required for Credentialing
Credentialing is paperwork-heavy, and that’s no surprise; after all, you’re proving that you’re qualified to provide medical care. Having the right documents ready from the start can make or break the speed of your application. Missing even one form can delay your approval by weeks or more.
Whether you’re a physician, nurse practitioner, therapist, or allied health professional, most credentialing applications will require a standard set of documents to verify your education, training, licensure, and experience. Here’s a checklist of commonly required items:
- Medical license(s)
- DEA certificate
- Board certifications
- CV/resume
- Malpractice insurance certificate
- Proof of education and training (diplomas, transcripts)
- Work history (with explanations for any gaps)
- Peer references
- Hospital privilege documentation
- CAQH login and profile
Missing even one of these can cause unnecessary back-and-forth with the payer.
Why Is Credentialing Essential?
Credentialing isn’t just another administrative task; it’s the foundation of trust, compliance, and safety in healthcare. Whether you’re a solo provider, part of a group practice, or managing a facility, proper credentialing ensures that everyone delivering care is qualified, competent, and authorized to do so.
- Ensures provider competence: It verifies that healthcare professionals meet national and state standards to work in the company.
- Builds patient trust: Patients want to know their provider is legitimate and trustworthy and can deliver the needed care.
- Protects your practice: Reduces liability and ensures compliance with payer and regulatory standards, and makes you reliable.
- Enables reimbursement: Without credentialing, you can’t join insurance panels or bill for services.
- Supports public safety: It filters out unqualified or fraudulent practitioners, those who play with the health of people. Legal actions are taken for them.
Final Thoughts
Credentialing might feel like paperwork overload, but it’s the backbone of safe, compliant, and paid healthcare services. Done right, it protects your reputation, keeps you in line with regulations, and ensures you get reimbursed on time.
If it feels like too much to juggle, let Ascend RCM’s credentialing services handle it for you. We know the rules, the timelines, and the shortcuts to get it done right, so you can spend less time on forms and more time caring for patients.
