Purpose

• According to the Utilization Review Accreditation Commission (URAC), a physician credentialing standard is required in order to determine that a provider possesses the necessary education, licenses and training to supply health care to consumers. This process provides critical information to insurance companies and hospitals in determining who is qualified to practice, bill and be paid for a particular service (a radiologist can bill for reading x-rays but not ordering the x-rays), who is part of the preferred provider network (PPO) or health maintenance organization (HMO) and whether provisional, restricted, courtesy or full hospital privileges are extended.
  
  

Procedure by Mail

• A credentialing application is completed stating the provider's name, if any other names have ever been used, gender, date-of-birth, place of birth, social security number, address, national provider identification number, drug enforcement administration identification number (if appropriate), state license number (if required), Medicare identification number, Medicaid identification number, undergraduate education, medical school, internship, residency, fellowships, specialty, contact information, practice location address, hospital privileges (must explain if there are none), malpractice insurance policy number and company, liability claims filed and their status. The provider then answers a list of disclosure questions ranging from suspensions or other sanctions, criminal history, drug use, physical or mental impairments and overall ability to perform provider duties. The provider signs the application stating that all the information is correct.
  
  The application, licenses, certificates and insurance face-sheet are then mailed to the insurance company or hospital who processes the request by verifying all the information. Once verification is complete, the application is either approved or denied and the provider is notified by mail.
  
  

Procedure On-line

• Some insurance companies such as Aetna, Humana and Blue Cross/Blue Shield are members of the Council for Affordable Quality Healthcare (CAQH). The Council for Affordable Quality Healthcare has a Universal Provider Datasource which permits providers to enter all the same data required on the paper application into a secure on-line database. This requires the provider to contact the insurance company who in turn registers the provider with the Council for Affordable Quality Healthcare. The Council for Affordable Quality Healthcare then issues a registration number, notifies the insurance company who then forwards the identification number to the provider.
  
  The provider creates an account with the Council for Affordable Quality Healthcare's Universal Provider Datasource and completes all the required information on-line. The provider then faxes the necessary licenses, signature pages and insurance face-sheets. The Council for Affordable Quality Healthcare Universal Provider Datasource then distributes this information to participating insurance companies who either approve or deny the application and notify the provider by mail.
  
  

Updating

• Insurance companies and hospitals set their own guidelines regarding how often a provider is credentialed to maintain their status. Usually a provider is credentialed for one to three years and then must re-credential by updating their application, licenses, certificates and malpractice insurance information. The insurance company or hospital usually notifies the provider when a re-credentialing is required or if an updated license, certificate or insurance face-sheet is needed and allows a certain number of days (30 to 90) for the provider to comply. If the provider does not respond within the required time frame, provider status is suspended. This physician is then no longer part of the network or may lose privileges and will not be paid for services rendered after the suspension date.
  
  If the Council for Affordable Quality Healthcare Universal Provider Datasource is utilized, verification of provider information is required every 90 days. If the provider has changes to their information, the Council for Affordable Quality Healthcare notifies participating insurance companies of the update. The Council for Affordable Quality Healthcare also notifies the provider or contact person to update file documents when a license or certificate is close to expiration.