FAQ

A credentialing committee is a group of professionals, typically within a healthcare organization, responsible for evaluating and verifying the qualifications of practitioners seeking privileges to practice at that facility. The committee reviews credentials such as medical licenses, board certifications, training history, work experience, and professional references to ensure that healthcare providers meet established standards of competence and quality.

The committee’s primary responsibilities include:

• Initial credentialing – Reviewing applications from new practitioners who wish to join the medical staff or obtain clinical privileges at the organization.
• Reappointment – Periodically re-evaluating current practitioners (usually every two years) to ensure they maintain their qualifications and have no concerning performance issues.
• Privileging decisions – Determining what specific procedures and services each practitioner is qualified to perform based on their training and experience.
• Quality assurance – Monitoring ongoing professional practice and addressing any concerns about competence, conduct, or patient safety.

The credentialing process helps protect patients by ensuring that only qualified, competent healthcare professionals are granted the authority to provide care within the organization. The committee typically includes physicians, administrators, and other healthcare professionals who bring expertise in evaluating clinical qualifications and organizational needs.

Yes, Medwave can assist with credentialing transitions when joining or leaving a practice. When joining a practice, we help ensure your individual credentialing is transferred or established correctly with all relevant payers, update NPI and provider enrollment information, and coordinate with the practice’s existing payer contracts to add you as a participating provider. When leaving a practice, we assist with notifying payers of your departure, establishing new contracts at your new location, transferring credentialing records, and ensuring continuity in your ability to bill for services. These transitions require careful timing and coordination to minimize gaps in your ability to see patients and receive reimbursement. We manage the administrative complexities so you can focus on patient care during these transitions.

Generally, you cannot bill insurance companies as an in-network provider until your credentialing is fully approved and effective. However, you may be able to see patients and bill them as self-pay or out-of-network during this period. Some insurance companies offer “interim” or “temporary” credentialing that allows you to begin seeing patients while full credentialing is being processed, though this is not universal. Once your credentialing is approved, some payers allow retroactive billing back to your application date or effective date, but this varies significantly by payer and contract terms. It’s crucial to understand each payer’s specific policies and inform patients about their potential financial responsibility during the credentialing period.

Maintaining credentialing status during evolving healthcare landscapes requires staying current with changing requirements. Many organizations have implemented temporary flexibilities for telehealth, cross-state practice, and documentation requirements that may continue or evolve. Keep all licenses and certifications current, even if renewal deadlines were extended. Maintain detailed records of any emergency privileges or temporary authorizations received. Stay in communication with your credentialing organizations about policy changes. Document any new skills, certifications, or training related to pandemic response or telehealth. Ensure your contact information and practice details are updated promptly as situations change.

If your credentialing application is denied, you’ll typically receive written notice explaining the reasons for denial. Common reasons include incomplete documentation, licensing issues, malpractice history, or gaps in work history that weren’t adequately explained. You have the right to appeal the decision by providing additional documentation or clarification. The appeals process varies by organization but usually involves submitting a formal written appeal within 30-60 days. Working with credentialing specialists can help you understand the denial reasons, gather appropriate documentation, and navigate the appeals process effectively. In some cases, you may need to wait a specified period before reapplying.

Key mistakes include submitting incomplete applications with missing signatures or documents, providing outdated or expired documentation, failing to disclose required information (gaps in employment, malpractice claims, disciplinary actions), not responding promptly to requests for additional information, and missing critical deadlines. Also, avoid using inconsistent information across different applications, neglecting to maintain current contact information with credentialing organizations, and failing to track renewal dates for licenses and certifications. Consider using credentialing services to help manage the complex requirements and timelines across multiple organizations.

Recredentialing is the periodic review and renewal of your credentials to ensure ongoing compliance with standards. Most organizations re-credential providers every 2-3 years, with hospitals typically following a 2-year cycle and insurance plans varying between 2-3 years. The recredentialing process involves updating your application with any changes to licenses, certifications, practice locations, or incidents, and may include peer review evaluations and quality metric assessments. It’s generally less intensive than initial credentialing but still requires attention to deadlines and documentation updates.

Essential documents include current medical license(s), DEA registration, board certifications, CV with complete work history, medical school diploma and transcripts, residency and fellowship certificates, malpractice insurance declarations page, hospital privileges documentation, and Medicare/Medicaid enrollment information. You’ll also need to provide references from colleagues, complete background check authorizations, and may need additional specialty-specific certifications. Keep digital copies organized and ensure all documents are current, expired items will delay the process.

Primary source credentialing usually takes 90-120 days, though it can extend to 180 days or longer depending on the complexity of your background and responsiveness of verification sources. Initial hospital credentialing often takes 120-180 days. Insurance payer credentialing varies widely, from 30-90 days for some plans to 120+ days for others. Factors that can delay the process include incomplete applications, delays from primary sources (medical schools, training programs, state boards), international education or training requiring additional verification, gaps in employment history, and high application volumes during certain times of year.

Medical credentialing is a process by which medical organizations verify the credentials of healthcare providers to ensure they have the required licenses, certification and skills to properly care for patients. It’s an essential function for hospitals and others which precedes hiring or obtaining coverage by an insurance carrier. Medical credentialing is perhaps most important because it’s the one method that permits patients to place their trust with utmost confidence in their chosen healthcare provider(s). Through a standardized process involving data collection, primary source verification and committee review by health insurance plans, hospitals and other healthcare agencies, patients are confident in their healthcare professional’s ability and experience.

Medical Credentialing is the process of contracting with Insurance companies in order to become an in-network or approved medical provider for that company. Becoming a participating provider for insurance companies in your area is an extremely important part of any medical practice. Whichever companies you are contracted with will dictate which patients you are allowed to treat and what your reimbursement rates will be.

Providers and hospitals have many questions in reference to on-board medical credentialing protocol(s). The following blog post, Credentialing (On-Board Process for Providers, Facilities)  discusses our overall protocol in detail.