Credentialing 101:
What You Need to Know
Credentialing athletic trainers with payors, hospitals, large
provider groups and health systems
Question: What does “credentialing” or “being credentialed” mean?
- 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.
- A credentialing process is utilized by health care facilities as part of its process to allow practitioners to
provide services on its campus, health plans to allow providers to participate in its network (provider
enrollment), and other health care entities that have a need to hire or otherwise engage providers.
- Privileging is the granting of permission to practice in an institution within the framework of defined
clinical practice.
Question: What is “being contracted” with a health plan/insurer?
- A contract (informally known as an agreement in some jurisdictions) is an agreement having a lawful
object entered into voluntarily by two or more parties, each of whom intends to create one or more legal
obligations between them. The elements of a contract are "offer" and "acceptance" by "competent
persons" having legal capacity who exchange "consideration" to create "mutuality of
obligation."[Elements of a Contract] www.contracts.uslegal.com
- A provider contract is one in which the provider agrees to the terms and conditions of the health
plan/insurer in order to be accepted as an In-Network Provider of said health plan/insurer.
Question: What is the difference between “being credentialed with” or “being
contracted with” health plan/insurer?
-
Contracting
– Contract between insurer and care provider for services rendered; the application includes
providing basic information of license, education, national provider identifier (NPI) number, including
state regulatory requirements, to become an approved provider of a specific health plan/insurer.
-
Credentialing
– Includes contracting application agreement in addition to liability protection for the health
plans constituents; includes providing full background of professional work and liability history, education,
state regulatory requirements, citizenship, etc. The health plan/insurer is verifying to their members that
the contracted professional has met the requirements of licensure, expertise, professional history, and
liability.
- Credentialing is an extra step above the contracting process, providing liability protection for both the
insurer and the insured.
- From the business/financial view point of the provider, being contracted with a health plan/insurer is just
as beneficial as being credentialed with the health plan/insurer.
- Some health plans/insurers decide to contract with athletic trainers (ATs) versus credentialed ATs
because the credentialing process is more resource intensive, and thus more costly; the increased liability
also may not be worth the increased cost to the insurer until the number of ATs that request
credentialing is higher.
Question: What is “provider enrollment” for contracting or credentialing? What is the
process?
Provider enrollment refers to the process of requesting participation in a health insurance network as a
participating provider. The provider enrollment process involves requesting enrollment/contracting with a
plan; completing the plan’s credentialing/enrollment application; submitting copies of licenses, insurance,
and other documents; signing a contract; and any other steps that may be unique to a carrier. Many
commercial carriers utilize the Council for Affordable Quality Healthcare (CAQH) to obtain credentialing
information from a central location and require that providers have a complete and up-to-date profile in the
CAQH system as part of the enrollment process.
Question: What is CAQH?
- Nonprofit alliance of health care organizations, including insurers, health systems, health maintenance
organizations (HMOs), and third party administrators (TPAs).
- In 2002, CAQH initiated Universal Provider Datasource (UPD).
- Full electronic solution saves time and resources.
- Simplifies and expedites provider data collection.
- Self-reporting of provider information for payors, hospitals, large provider groups, and health systems.
- Supported by all major insurance and provider associations.
- Many health plans...one solution! The leading, industry-wide service to address one of health care
providers’ most redundant administrative tasks: the credentialing application process.
- Under the CAQH program, health care providers use a standard application and a common database to
submit one application to one source to meet the needs of all of the health plans and hospitals
participating in the CAQH effort.
- Health plans and hospitals designated by health care providers obtain the application information directly
from the database, eliminating the need to have multiple organizations contacting the provider for the
same standard information. Providers update their information quarterly to ensure data is current and
accurate. CAQH gathers and stores detailed data from more than 1.3 million health care providers
nationwide.
- CAQH Software update
occurred March 2, 2015. This update has been named ProView
.
Prior to this
update, AT was not included in the list of health care professionals; with ProView, ATs gained access.
- Data set meets the data collection requirements of the Utilization Review Accreditation Commission
(URAC), the National Committee for Quality Assurance (NCQA), and Joint Commission Accreditation
standards.
- Supported by America’s Health Insurance Plans (AHIP), American Academy of Family Physicians (AAFP),
American College of Physicians (ACP), American Health Information Management Association (AHIMA),
American Medical Association (AMA), and Medical Group Management.
- Fully electronic solution saves time and eliminates need for redundant, time-consuming paper forms and
faxes.
- Simplifies provider data collection by only prompting to enter the data required for the state(s) where a
provider practices.
- Updated information is immediately available to organizations authorized by the provider.
- With ProView, for the first time, ATs are included in the list of licensed providers.
CAQH ProView – Benefits to Providers
- Free service to providers.
- Easy to use.
- Enter, submit, and store all data electronically.
- Eliminates the need for time-consuming paper forms.
- Enhanced security features help you maintain total control of your information.
- Re-attest in minutes.
- Updated information is immediately available to organizations authorized by the provider.
AT Credentialing through CAQH ProView
- With ProView –
ATs are included in the list of licensed providers.
- Providers enter, submit, and store all credentialing data electronically for participating organizations.
- See CAQH ProView Provider Quick Reference Guide (PDF) to help you get started.
Visit nata.org for more information on credentialing.
For more information, and to start the process of entering credentialing information, visit
https://proview.caqh.org/pr.
For more information on credentialing, billing and/or reimbursement, contact:
Amy Callender
NATA Director of Government Affairs
1620 Valwood Parkway, Suite 115 Carrollton, Texas 75006 | 214.637.6282 | www.nata.org
