Credentialing

Credentialing Checklist for Healthcare Providers

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September 13, 2021

Whether you are fresh out of medical school or you have been practicing for a while, credentialing is a stressful but necessary step in the process of being a licensed healthcare provider. 

What Is Hospital Credentialing or Healthcare Credentialing?

Hospital credentialing also known as healthcare credentialing is the method of verifying that a provider is qualified to administer medical services. Credentialing process is expensive and time-consuming, it is lawfully required and ensures quality and safety for patients. Executed accurately, credentialing also guard providers and hospitals.

Through hospital credentialing, the hospital demands information from the provider about the provider’s education, experience, licensure, training, insurance, and background. It then verifies that the provider’s credentials are valid, authentic, and current.

Healthcare credentialing and privileging

Healthcare credentialing and privileging are different methods. Hospital credentialing, which happens first, verify the qualifications of a provider. After credentialing, privileging rewards the provider the authority to practice medicine.

Why is credentialing important in healthcare?

Credentialing is important to gain the confidence of your patients so that you can offer them good quality, cost-effective and essential medical care. It is also vital to be credentialed because employers need to know that you possess the necessary training and certifications to provide quality services. Credentialing also impacts whether a hospital or healthcare facility can bill for you.

The credentialing process is generally stressful, and it can take up to 120 days, assuming you have filled your form correctly and submitted the appropriate documents. 

In the past, hospitals and healthcare facilities would send paper documents back and forth to request copies of your documents. In the modern age, the credentialing process has been streamlined with an automated system that allows you to upload your forms, practice affiliations, and other credentials online for your potential employer to review. 

This new method greatly reduces error, saves time, and allows you to focus on other essential matters like providing quality care to your patients. 

Documents checklist for medical credentialing:

The credentialing checklist helps healthcare professionals know what is required of them to be qualified to offer certain healthcare services. It provides an overview of what documentation they will need to gain the confidence of prospective employers, patients, and other healthcare bodies.

Below is a credentialing checklist to help you stay up-to-date on what is required of you to practice safely and legally. We recommend that you always ensure you are up-to-date with your credentialing documents. 

  • Addresses, phone numbers, and other personal information.
  • A current photograph, signed and dated on the margin.
  • Medicare number.
  • Medicaid number.
  • Copy of National Provider Identifier (NPI) documentation, along with confirmation letter.
  • UPON number.
  • Tax identification number.
  • An original copy of your federal DEA registration and any current state controlled substance certificate(s).
  • A copy of your current driver's license or passport.
  • Non-US citizens must submit a copy of their green card or permanent resident card (if applicable).
  • Diploma and certificate(s) associated with your medical school training, internship experiences, residency, and fellowships.
  • Current CME activity (CME activity for the past three years).
  • A copy of the current Board Certificate, including the board's name issuing the certificate and the date of recertification.
  • Copy every valid state license wallet card(s) and wall certificate with expiration date and numbers.
  • Current Curriculum Vitae with complete professional history and no gaps (include month and year).
  • Affiliations with hospitals and facilities.
  • Completed Delineation of Privileges Form.
  • An overview of your work history, including your employment affiliations and locations of practice.
  • Discipline and explanations, if applicable.
  • A detailed history of malpractice claims.
  • (If applicable) Certificate of Professional Liability Insurance coverage (face sheet) of the policy.
  • Documentation from third parties (e.g., court documents, dismissals) disciplinary/malpractice actions OR completion of an explanation form (if applicable).
  • There should be at least three letters of recommendation from providers who had directly observed you in practice within the past year (they should assess your clinical competence and specify when they last observed you).
  • Discharge record from the military - Form DD-214 (if applicable).
  • TB test results from the last TB test (if available).
  • (If applicable) Case log from the last 24 months.
  • Mammo #s and MQSA (if applicable).
  • Copy of FLEX, NBME,  SPEX, or USMLE scores.
  • A copy of any one of the following: BLS, ACLS, ATLS, PALS, APLS, or NRP certificate(s).
  • Completed Locum Tenens Practice Experience Form (if applicable.
  • If you are a foreign graduate, provide your ECFMG certificate number and information about the Fifth Pathway.

Physician Credentialing Checklist

Whether you’re beginning a new practice or you’re adding additional practitioners to your clinic going through the physician credentialing process is important. Credentialing time-consuming process, to help you we have developed a checklist that will help you make the process move smoothly.

Here’s our ultimate physician credentialing checklist:

Adding Providers to New Practice

This checklist is for people who are starting up a new practice from scratch and are looking to guarantee that each one of your providers has followed the credentialing process properly.

Steps

  1. Establish a new group in your state, and acquire your Tax ID information from the IRS.
  2. Download the e-file (CP-575) when gathering the information on your EIN.
  3. Give the address where your practice is located. Considering you are now established as a private medical practice, this information can be easy to achieve.
  4. Upon finishing the previous steps, you can then apply for a Group NPI.
  5. Update your attested CAQH profile with your CAQH ID.
  6. Identify the payers you’re seeming to credential with, including commercial PPOs or HMOs, Medicare, Medicaid, Worker’s Compensation, Tricare, or any other payers around you that you may find at your practice.
  7. Produce a W9 form with your billing address.
  8. Because hospital credentialing will be needed for different specialist services and will be asked by insurance providers for credentialing, assure that the credentialing process is in progress with local hospitals or have a covering provider.
  9. Permanent office phone and fax numbers should be included on your CAQH and other applications.
  10. Implement a malpractice policy, as this is a necessity for most insurance companies.
  11. As you’re updating your CAQH, be sure to have approved access to your profile for relevant insurance companies.
  12. For applying with Medicaid, you will require a business license, articles of incorporation, group/practice liability insurance and worker’s compensation insurance, CLIA certification or waiver if applicable.
  13. After completing all these steps, you will be capable to submit letters of interest or applications to payers that you are wishing to utilize at your practice.

Practice Documentation Checklist

  • CP575 OR 147C Letter
  • Signed and completed W9 form
  • Business license
  • Fictitious name permit (applicable for state) 
  • Articles of incorporation or organization
  • Liability insurance coverage
  • Worker’s compensation insurance coverage
  • CLIA certification or waiver
  • EFT verification from your bank or a voided check

Provider Documentation Checklist

  • Professional license
  • DEA certification
  • CDS certification
  • Board certification or proof of eligibility
  • PLI certification
  • Professional school diploma
  • Certification of completion for internships, fellowships, or residencies
  • CAQH login and password
  • PECOS login and password
  • State Medicaid login and password
  • Availity system login, password, and backup codes
  • Current CV with exact beginning and ending dates
  • Hospital admitting privileges or covering provider

Adding a New Provider to Current Practice

You can use this checklist if you are now operating a medical practice and want to add a new provider to your current staff.

Steps

  1. Provide an updated CAQH profile, with the new practice association listed. The provider’s license and DEA must also be updated with the new state they’ll be working in if this is different from their initial association.
  2. The group the provider will be added to will require to supplement a list of payers they are currently affiliated with, including commercial, Medicare advantage, Medicaid HMOs, worker’s compensation, Tricare, as well as any TPAs.
  3. Supply Tax ID to insurance companies and update your CAQH profile with this data as well.
  4. As hospital credentialing is necessary for some insurance payers or specialty providers, the list of hospitals you intend to have privileges with will require to be updated in your CAQH profile. If you don’t plan on having hospital privileges for your practice, you will need to create an admitting arrangement with a provider, or decide which hospitalist or ER in your area you will be using for admitting arrangements.
  5. Implement a new or updated malpractice policy and update your CAQH profile.
  6. Present the group’s primary billing type, which will be listed on applications with Tax ID.
  7. Provide the group’s Medicare PTAN that you intend to be added on, which will be recorded on your Medicare application linked to the new group.

Provider Addition Documentation Checklist

  • Professional state license
  • DEA certification or covering provider name
  • CDS certification
  • Board certification or proof of eligibility
  • PLI certification
  • Professional school diploma
  • Certificates of completion for internships, fellowships, or residencies
  • CAQH login and password
  • PECOS login and password
  • State Medicaid login and password
  • Availity login, password, and backup codes
  • Current CV with exact beginning and ending dates
  • Hospital admitting privileges or covering provider

Credentialing Process with FloatCare

With FloatCare, you are taking off the burden and eliminating the errors when you manually submit your forms. We take the time, hassle, and mistakes out of the credentialing process for you. Know when to get re-credentialed with the help of our unique monitoring that sends you alerts when we think your credentials may be expired. And we do that swiftly, 

Sign up today!

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