Credentialing

Credentialing is the process of establishing the qualifications of licensed medical professionals

and assessing their background and legitimacy.

Credentialing is the process of granting a designation, such as a certificate or license, by assessing

an individual's knowledge, skill, or performance level. In healthcare industry Credentialing (http
s://www.ncbi.nlm.nih.gov/books/NBK519504/#:~:text=Credentialing%20is%20a%20formal%20
process,their%20ability%20to%20practice%20medicine) is defined as a formal process that
employs a set of guidelines to ensure that patients receive the best possible care from healthcare
professionals who have undergone the most stringent scrutiny regarding their ability to practice
medicine.

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.

Contents
Insurance credentialing / medical credentialing
Credentialing Special Circumstances: Telemedicine
The Joint Commission for Medical Credentialing
Process of Credentialing
Types of credentialing
Personnel credentialing
Political credentialing
Paperless credentialing
Credential Verification Organizations
See also
References

Insurance credentialing / medical credentialing

Credentialing is the process the healthcare facility or managed care organization/health plan uses
to collect and verify the “credentials” of the applicant. This includes verification of many elements
including licensure, education, training, experience, competency, and judgment.[1]

Physicians and other healthcare providers who wish to provide care in a hospital, ambulatory care
facility, or other healthcare facility must undergo an application process which includes
verification of credentials. Additionally, providers that want to bill an insurance company and
receive reimbursement for services as an in-network provider must undergo a process of
credentialing. Healthcare facilities and health plans will verify relevant education including
medical school, residency/fellowship training, board certification, licensure, professional liability
insurance and claims history, and will query the National Practitioner Data Bank (NPDB). The
NPDB is an electronic repository containing information on medical malpractice payments and
certain adverse actions related to healthcare practitioners, entities, providers, and suppliers.
Although the basic aspects of credentialing are performed in the same way, there are different
credentials verified depending on the environment. For example, hospitals will typically request
information concerning procedures performed in order to document that the applicant is meeting
current competency requirements for privileges requested, but health plans (insurance companies)
do not typically collect this information because health plans do not grant privileges. Since
healthcare facilities grant clinical privileges, these organizations will also write to contact other
facilities where a provider has worked and obtain professional references to verify experience,
competency, and to determine whether any disciplinary actions were taken against the provider.
[2]

The approval process in a healthcare facility typically involves a review of the applicant’s
credentials and qualifications with recommendations for appointment and privileges made by the
medical staff via a department chairperson, the credentials committee, and the medical executive
committee. The approval process varies depending on the medical staff structure. The actual
approval of privileges and appointment is made by the board of directors. Some healthcare
facilities have a mandatory requirement for interviews, and some hospitals will only interview
physicians under certain circumstances as defined in their the medical staff’s bylaws.

In a health plan, the credentialing process differs from that of a hospital. In a health plan, the
provider enrolls in the provider panel network. After the application is submitted and credentials
are verified, the approval process will involve review and approval by the network’s medical
director or credentialing committee.

Typically, insurance companies require credentialing for the following providers

Physicians MDs, DOs

Dentists
Physical Therapists,
Speech Therapists
Psychology Counselors
Occupational Therapists
LMFT
Group Medical Practices
Clinics
Hospitals
DME Companies
Home health agencies

Provider credentialing is different from provider enrollment. Provider enrollment is the process of
enrolling a provider with insurance payers. The provider must submit a credentialing application
that details their training and qualifications to treat patients in their area of specialty. While
hospitals and health systems typically have their own provider enrollment team to perform this
function, independent group practices and solo practitioners may contract with another
organization to perform this function.

Credentialing Special Circumstances: Telemedicine

The Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) allow
an originating site facility to use proxy credentialing when telemedicine services are provided by a
practitioner affiliated with and credentialed by either a Medicare-participating distant site hospital
or an entity that qualifies as a distant site telemedicine entity; and when there is a written
agreement that satisfies certain requirements that are enumerated in the regulations. This allows
the parties to share information regarding credentialing decisions, as well as periodic updates of
practitioner reviews and assessments. While healthcare accreditation organizations have largely
aligned their standards with CMS regulations, each state has its own regulations regarding
hospital licensure and many states’ regulations include regulations governing the structure and/or
operation of the medical staff, including credentialing requirements.[3]

A healthcare facility may choose to utilize credentialing by proxy under the CMS regulations for
telemedicine providers, or it may utilize the process specified in the medical staff bylaws and
policies and procedures for other medical staff appointees.

The Joint Commission for Medical Credentialing

TJC (formerly known as JCAHO) was founded in 1951 and accredits and certifies healthcare
organizations to meet quality standards. It envisions a future in which TJC is "leading the way to
zero," which translates to zero harm in healthcare.

TJC, or the Joint Commission,[4] accredits and certifies over 22,000 healthcare organizations and
services in the United States. TJC accreditation establishes a baseline for patient safety and
process improvement. Healthcare facilities which want to supply services to Medicare, Medicaid
and other Federal healthcare plans may utilize Joint Commission accreditation in lieu of being
surveyed by the State Health Department.

Process of Credentialing
Credentialing [5] requires more comprehensive data of the professional, political member or a
group of professionals. The process of credentialing includes verification of the information such
as:

Education and training

Residency
Licenses
Specialty certificates
Qualifications
Career history

Types of credentialing
There are three types of Credentialing

Personal Credentialing
Political Credentialing
Paperless Credentialing

Personnel credentialing
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 credentialing
Political parties credential delegates at their conventions. Credentialing is required for the UN
representatives in the General Assembly. A Credentials Committee[6] consisting of nine members
is appointed at the beginning of each regular session of the General Assembly. The Committee
reports to the Assembly on the credentials of representatives.

Paperless credentialing
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.

Credential Verification Organizations

Some of Credentials verification Organizations in healthcare industry are as follows

National Practitioner Data Bank

The American Board of Medical Specialties
American Association of Nurse Practitioners (AANP)/American Nurses Credentialing Center
(ANCC)
The Office of Inspector General (OIG) and the System for Award Management (SAM)
Medical Board of Each US state

See also
Medical credentials
Economic credentialing
Actuarial credentialing and exams
License
Certification
National Association Staff Services

References
1. The Clinicians Quick Guide to Credentialing and Privileging
2. The Clinicians Quick Guide to Credentialing and Privileging
3. The National Association Medical Staff Services (NAMSS) NAMSS-American Telemedicine
Association (ATA) Credentialing by Proxy (CBP) Guidebook
4. "Leading the Way to Zero | The Joint Commission" (https://www.jointcommission.org/).
www.jointcommission.org. Retrieved 2022-04-04.
5. Olson, Debra Kay; Verrall, Brian; Lundvall, Ann Marie (May 1997). "Credentialing" (https://journ
als.sagepub.com/doi/pdf/10.1177/216507999704500504). AAOHN Journal. 45 (5): 231–238.
doi:10.1177/216507999704500504 (https://doi.org/10.1177%2F216507999704500504).
ISSN 0891-0162 (https://www.worldcat.org/issn/0891-0162).
 6. "General Assembly of the United Nations" (https://www.un.org/en/ga/credentials/credentials.sht
ml). www.un.org. Retrieved 2022-04-04.

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