Credentialing How Tos   /   October 2019

3 Things to Know About a Typical Credentialing Committee

3 Things to Know About a Typical Credentialing Committee

What is a credentialing committee, and what is it comprised of?

A Credentialing Committee is a body of practitioners responsible for 1) accepting and denying providers into a plan’s provider network at the initials credentialing event; 2) monitoring the participating providers; and 3) and making determinations for ongoing participation at the providers’ re-credentialing upon application. 

Comprised of providers of a similar specialty to those that participate in the managed care network, a Credentialing Committee typically meets monthly, or more frequently as needed to address the health plan’s business needs. 

One of the most important jobs of the Committee is to report any disciplinary actions taken against a provider to the National Practitioner Data Bank (NPDB) and other entities

What is the responsibility and goal of the Committee?

The objective of the Committee is to ensure that the plan’s network is credentialed and re-credentialed according to standards. Typically, the Committee will follow industry standards (such as NCQA), in addition to state and federal requirements. 

Another important aspect of the Committee’s role is to provide oversight and guidance to the credentialing department. As part of that oversight, it is mandated to ensure the health plan’s credentialing program incorporates any new or changing state and federal requirements into its policies.   

The Credentialing Committee is also responsible for Delegated Credentialing oversight.  Prior to receiving delegated status, an organization must be reviewed by the Committee to ensure they adhere to the health plan’s credentialing policies and procedures. Once the organization achieves delegated status, it must also be reviewed by the Committee on an annual basis to ensure they are still meeting the required criteria.

How are meetings recorded?

Meetings of the Committee are confidential in nature, and all of the files and materials discussed and presented to the Committee must be confidential as well. Minutes are kept of each meeting documenting who was in attendance, the providers reviewed at Committee, and the items discussed. The minutes of the Committee are also confidential.

Keeping detailed notes of Committee meetings is critical to staying compliant, and to having archived records of what decisions have been made in meetings. We recently rounded up our best practices around running committee meetings, and even provide a free template for Committee notes that you can download and use. Click here to read about running efficient meetings and to download the template.




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