Hospital Credentialing 101

Credentialing and Privileges

In the realm of healthcare, the process known as hospital credentialing plays a crucial role in verifying the qualifications of medical providers to ensure the delivery of safe and high-quality medical services. While this process can be resource-intensive and time-consuming, it stands as a legal requirement that underpins patient safety and quality care within healthcare settings. Moreover, effective hospital credentialing not only safeguards patients but also offers protection to healthcare providers and institutions.


It’s essential to distinguish between credentialing and privileging, two terms often used interchangeably. Hospital credentialing, the initial step, entails verifying the qualifications of a provider, while privileging follows, granting the provider the authority to practice medicine within a specific healthcare facility.


Getting It Done

Before physicians can commence their services, their credentials undergo thorough verification to confirm their competence and legal eligibility to practice. During hospital credentialing, providers are required to submit detailed information encompassing their education, work experience, licensure, medical training, insurance coverage, and background. This information is meticulously scrutinized to ensure accuracy, authenticity, currency, and good standing.


The hospital credentialing process varies across institutions, yet it invariably necessitates specific documentation. This usually includes many the following:

  • state licenses
  • certification statuses
  • surgical logs
  • documentation of hospital privileges
  • insurance claims reports
  • updated resumes
  • certifications in medical procedures like ACLS/BLS, DEA certificates
  • immunization records
  • educational diplomas
  • professional references
  • residency certifications
  • personal identification documents

Additionally, credentialing may encompass background checks and sanction verifications conducted by regulatory bodies such as the Office of Inspector General (OIG), typically involving direct communication with primary sources and cross-referencing records for consistency.


Upon successful verification of documentation, the applicant’s files are reviewed by an executive committee within the hospital. This committee may engage in discussions with the applicant and relevant stakeholders before approving the application and forwarding the information to regulatory bodies like the Joint Commission for further scrutiny.


Getting to Work

Once hospital credentials are secured, physicians may be granted privileges to practice within the healthcare facility. These privileges are categorized into three types: active or admitting, courtesy, and surgical, each delineating specific scopes of practice within the hospital environment.


Telehealth credentialing presents unique challenges, particularly for smaller healthcare facilities and practitioners. The conventional credentialing and privileging process can pose significant barriers to telehealth patients’ access to care, exacerbated during emergencies such as the ongoing pandemic. To expedite credentialing, practitioners may opt for “credentialing by proxy,” a method allowing them to practice at distant sites under the oversight of associated originating sites like hospitals.


While the Centers for Medicare and Medicaid Services (CMS) have introduced measures like credentialing waivers during crises, adherence to specific regulations remains paramount. Key requirements for credentialing by proxy include signed agreements, valid licensure, evidence of privileges at distant sites, and certification of distant sites as Medicare or telehealth facilities. Additionally, ongoing performance reviews and complaint sharing between originating and distant sites are crucial for regulatory compliance.


Despite its significance, the hospital credentialing process often encounters delays due to common roadblocks. These include missing or incomplete information on applications, varying state regulations, and misconceptions regarding credentialing responsibilities among healthcare organizations. Addressing these challenges requires thoroughness in application submissions, awareness of state-specific regulations, and clarity regarding organizational responsibilities.


We Can Help

In response to the complexities of hospital credentialing, credentialing assistance services like Red House offer solutions to streamline the process. By providing end-to-end credentialing support, primary source verification, continuous monitoring, and background checks, Red House helps healthcare institutions save time and resources while ensuring compliance with credentialing standards and enhancing patient safety.


If you’d like help managing your hospital’s credentialing and privileging processes, digital management, or to build an internally managed offshore team, reach out to schedule time with the team at Red House.

Questions You’ll Ask Before You Start Provider Enrollment

How do I know which insurances I need to enroll with?
· We suggest the major payors in your region as a starting point
· What patients have you turned away because you are out of network, or unsure of your network status with their plan?
· Who is your patient base? If geriatrics, Medicare would be a good option. Pediatrics? Medicaid.


How long does the payor enrollment process take to finalize?
· Each insurance company processes applications on their own timeline. Typically, 90-120 business days.


What information and documents are required to enroll with insurance networks?
· Documentation can vary due to specialty, practice type, geographical location, etc.
· Most common information required is Demographics, NPI, Licensure, Work History, Education History, and Malpractice Coverage


What is CAQH, and is it required?
· CAQH ProView is an online provider data-collection tool utilized by many health plans in lieu of a traditional paper credentialing application.
· It is now required by most commercial health plans.
· More information on CAQH ProView can be found on their website


What happens if I don’t want to accept the payor’s offered reimbursement rates?
· It’s an offer, until you sign. Negotiate!
· Still not meeting your needs? Time to choose whether to sign or not. Is the volume worth the low rate? Potential to re-negotiate in a reasonable timeframe? The final decision is always yours.


When can we start treating members?
· Once the payor has credentialed, contracted, and assigned an effective date.
· If you choose to see members prior to the effective date, the claims will process as out of network. Check eligibility and benefits prior to the appointment to ensure the patient has out of network benefits.


We are in network, but claims are denying; why?
· This is potentially a load issue on the payor end. At times, the credentialing/contracting departments will reflect in network, but the load file has not completed. This will cause false denials. It is important to ensure your contract is fully loaded with the payor prior to submitting claims, unless close to timely filing.