Why CAQH is Required for Provider Credentialing?

Credentialing is a systematic approach to the collection and verification of a health care provider’s professional qualifications. The qualifications that are reviewed and verified include, but are not limited to, relevant training, licensure, certification and/or registration to practice in a health care field, and academic background. Insurance credentialing is the process of becoming affiliated with insurance companies to ensure health care providers can accept third party reimbursement.

There are a lot of misconceptions about CAQH, what it is, what it does, and why it’s used.  We’re going to answer these questions and tell you how to register with CAQH. CAQH is an online data repository of credentialing data. Provide credentialing using CAQH refers to the process of practitioners self-reporting demographics, education and training, work history, malpractice history, and other relevant credentialing information to create an online credentialing profile for insurance companies to access.

Electronic access to this information is meant to reduce the burden of paperwork by eliminating much of the paper-based enrollment process involved with payor network enrollment and facility privilege applications.

What is CAQH?

CAQH functions as a giant database that insurance companies and credentialing companies can pay to access. CAQH does not submit applications to insurance companies or complete the credentialing process but they do play a vital role in this process. Think about your license, malpractice policy (COI), DEA certificate or anything else that routinely expires without your intervention.

These documents are needed by the insurance companies and rather than providing each payer an updated license, you can upload this document into CAQH, attest to its accuracy and grant the payers permission to access the file.

Not all plans have access to CAQH so it’s important to not assume all payers will have your information once your profile is built. Most local/regional health plans do not access it and none of the government payers use it. Note that CAQH is not used by Medicare, Medicaid, or Tricare.

CAQH and Credentialing

CAQH is used for initial credentialing and for payer recredentialing. This means that it’s not a set it and forget it database but requires maintenance on your part.  When you’re first getting credentialed with health plans, sometimes payers will use your CAQH application/profile and export it into their system.

In order to accomplish this, the payer has to be authorized and will often request your CAQH id number over the phone, online, or via email. Once you’re up and running which includes getting contracted the payer will likely use CAQH to keep your file up to date. This is why remembering to re-attest every 90 days and keep your documents updated is so important.

Importance of CAQH

CAQH is required by many insurance companies so you really don’t have much of a choice. There are exceptions to this as a handful of states have their own system which functions much like CAQH.  However, even if your state has it’s own system, it still makes sense to register with CAQH as some of the national plans reluctantly use the state system but ultimately prefer CAQH.

In addition to being a requirement in most states, it improves efficiency by cutting down the number of redundant applications or requests for info that have to be handled.

Registering with CAQH

While you’re not required to complete the CAQH in one sitting (that could take hours), it is better to have all the required information and materials ready ahead of time to speed up the process.

• Here’s some information you’ll need to complete the CAQH:
  • Basic personal information
  • Education and training
  • Specialties and board certification
  • Practice location information, including the practice name and type, address, contact information, services, certifications, limitations, hours, partners, covering colleagues, billing, office manager, and credentialing contact
  • Malpractice insurance information
  • Work history and references
  • Disclosure and malpractice history
  • CV or resume
  • Malpractice insurance policy(ies)
  • W-9(s)
  • State license(s)
  • Various ID numbers (UPIN, NPI, etc.)
  • Drug Enforcement Administration (DEA) certificate (if applicable)
  • Controlled and Dangerous Substances (CDS) certificate (if applicable)
• Once you feel like you have everything ready for submission, visit: https://proview.caqh.org/PR/Registration/SelfRegistration
• Once you’ve made it through to the end of the application, you now need to grant the payers access to your information. Before they can do this, you must submit a signed attestation document provided by CAQH. This is you verifying that you’ve submitted accurate information and tells the payers that your application is ready for review.
• Once you sign & date the release/attestation, you want to make sure and remember to upload the document through their document
• Be sure to save your CAQH ID #, user id, and password. Keep this in a safe place and remember to check it every ninety days to ensure nothing needs your attention. CAQH is supposed to email you or whoever you put as the credentialing contact but you don’t want to rely on their reminder.

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