Credentialing is the process of obtaining, verifying, and assessing the qualifications of a practitioner to provide services or care in or for a health care organization. Credentials are documented evidence of licensure, education, training, experience, or other qualifications. A medical practitioner cannot work at a hospital legally or partner with insurers, without proper medical credentialing. Only a new physician or practitioner who is credentialed is allowed to see patients, treat hospital inpatients, and receive insurance reimbursements.
Practitioners are privileged and credentialed. It means your organization verifies the qualifications, education, and license at the time of hiring and every two years (except Illinois, which is every three years).
The credentialing authority (Credentials Verification Organization or CVO) will contact the university where the provider received their degree in medicine, had their training, and did their residency, to verify their credentials.
They will also contact licensing agencies and certification boards to verify licenses and specialty certificates. Hospitals and other employers can provide confirmation of employment history.
Privileges are granted by the governance of the organization after evaluation of the training and education the provider has presented. Privileges allow the physicians to perform, or give the care treatment and services requested by the organization to their patients.
The facility that you intend to work with may have a credentialing service that they use. You can request an application by contacting the provider representative in the appropriate department. Depending on the CVO, you may receive the application and all other documents by mail, email, or fax. After completing your application, review the application checklist and then submit the application.
Before you begin any credentialing process, the most important item you can prepare is a comprehensive curriculum vitae (CV) or resume. It is critically important that you are complete and accurate with the information in your CV—and that you keep it updated—as it will be the basis from which your applications are completed and background verifications are made.
Each application will also have a section of confidential questions regarding adverse actions, previous sanctions, malpractice claims/suits, impairments, and criminal history, etc. You will be asked to provide specific details if you have given a positive answer to any of these questions, these will necessitate further investigation by the credentialing department. Ensure that you answer these questions with complete honesty as there are different ways that facilities will discover this information. If you are dishonest on the application, it can result in immediate termination from a plan or loss of hospital privileges.
Finally, the best way to ensure that your file gets priority attention is to complete the application and submit all the required documents as quickly as possible. Incomplete information and Delays will only hurt your processing time. Returning your materials in a timely manner will also help you in establishing a good relationship with the credentialing staff at facilities where you wish to be employed.
All active state medical licenses
Current federal DEA registration
Active state drug permits (controlled dangerous substance permits)
Medical school diploma
ECFMG certificate, if applicable
Residency certificate(s)
Internship certificate, if applicable
Fellowship certificate(s)
Documentation regarding National Provider Identifier (NPI)
Specialty board certification(s)
Current certificate of malpractice liability insurance (COI) showing your name as a policyholder, dates of coverage, limits of coverage, any limitations or exclusions
· Patient’s name and plaintiff’s name (if different)
· Your involvement in the case
· Diagnosis
· Your status in the case
· Allegation by the plaintiff
· Clinical summary of the case
· Patient outcome
· Date of the incident
· Date closed
· Settlement date
· Resolution or the current status of the claim
· Amount of any settlement paid
· Professional liability malpractice insurance carrier; address, name, and policy number
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