The document outlines the provider credentialing process, which is essential for verifying healthcare providers' qualifications to ensure patient safety and care quality. It details initial credentialing, recredentialing, and network participation, as well as steps like application submission, primary source verification, background checks, committee review, contract negotiation, and ongoing maintenance of credentials. This process is necessary for providers to participate in insurance networks and receive reimbursement for services.

1. Provider
Credentialin
g
Process

2. • The process of verifying a healthcare provider's qualifications
and credentials to ensure they meet the standards for
providing patient care.
• Ensures patient safety and quality of care.
• Involves a thorough review of education, training, licensure,
certifications, and work history.
• Necessary for providers to participate in insurance networks
and receive reimbursement for services.
What is Provider
Credentialing?

3. Types of Credentialing

4. Types
The initial process of verifying a provider's credentials
for the first time with an insurance company.
Initial Credentialing
The ongoing process of re-verifying a provider's
credentials at regular intervals (typically every 2-3 years)
to ensure continued compliance.
Recredentialing
Network Participation
The process of enrolling with a specific health insurance
network to become an in-network provider.

5. The Credentialing
Process

6. • Application Submission: Providers submit an application to the insurance
company, including detailed information about their education, training,
licenses, and certifications.
• Primary Source Verification: The insurance company verifies the
information provided by the provider through primary sources (e.g.,
medical schools, licensing boards).
• Background Checks: Background checks may be conducted to verify
information and identify any potential concerns.

7. Process Cont.
• Committee Review: A credentialing committee reviews the
application and supporting documentation to determine
eligibility.
• Contract Negotiation: Once approved, a contract is
negotiated between the provider and the insurance
company outlining terms of participation.
• Ongoing Maintenance: Providers are responsible for
maintaining their credentials and notifying the insurance
company of any changes.

8. Thank
You!