Credentialing How Tos   /   November 2019

Breaking It Down: What is credentialing?

Breaking It Down: What is credentialing?

 

1.What is Managed Care/Health Plan Credentialing?

Credentialing is the process of obtaining, verifying and assessing the qualifications of a practitioner/provider to provide care or services in or for a Healthcare Organization. Credentials are documents of evidence of licensure, education, training, experience, and other qualifications. 

2. The Purpose and Importance of Credentialing

Credentialing helps to ensure a provider has received the education, training and has the clinical competence and experience to practice safely and efficiently. Health Plans and Managed Care Organizations (MCO) credential providers to ensure their members have access to qualified medical providers.

Health Plans and MCOs can face quality issues, poor patient satisfaction among other issues if providers are not properly credentialed by allowing unqualified providers to perform health care services.

3. Who needs to be credentialed?

All providers including facilities and ancillary providers who will be providing care, need to be credentialed and re-credentialed to be sure they have the current credentials or have maintained the required credentials to provide quality care to patients. maintained

4. Who is responsible for credentialing?

Health Plans and MCO’s Insurance and Managed Care plans are responsible for credentialing providers prior to allowing them to be participating providers in their networks and treat members.  

5. How are credentials verified?

There are many ways to credential a provider but the National Committee for Quality Assurance (NCQA) has set standards to ensure a provider is fully vetted. The NCQA standards are among the highest standards for credentialing and re-credentialing and include verification of licensure, education, malpractice information. Please note that there are several other Accrediting Bodies  (i.e. The Joint Commission) that accredit healthcare entities including Health Plans and MCOs but for the purposes of this post we are focusing on NCQA. 

6. Credentialing versus Re- Credentialing

During the Initial Credentialing process, a provider is required to complete an application that includes their education and training, malpractice history, work history, licensure information, Drug Enforcement Agency (DEA) certificate if applicable, hospital privileges, sanctions status with Medicare/Medicaid and other credentialing documents  as well as an attestation that they are able to provide the essential functions of their duties. This information is verified and reviewed by the Credentialing Committee so they make take action based on the Credentialing information they have been presented with.

Re-credentialing is completed at least every 36 months according to NCQA standards and requires an application to be completed and updated at that time. information that is non-static (changed or could have expired, i.e licensure, malpractice, board certification among others) verified at this time, ensuring the provider meets the credentialing standards set by NCQA and the health plan or MCO and does not have any issues related to the quality of care

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CredSimple is an NCQA certified CVO and can assist you with all of your credentialing needs.

 

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