Credentialing

Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy. Many health care institutions and provider networks conduct their own credentialing, generally through a credentialing specialist or electronic service, with review by a credentialing committee. It may include granting and reviewing specific clinical privileges, and allied health staff membership. Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy. Many health care institutions and provider networks conduct their own credentialing, generally through a credentialing specialist or electronic service, with review by a credentialing committee. It may include granting and reviewing specific clinical privileges, and allied health staff membership. Physicians and other healthcare practitioners who wish to bill an insurance company and receive reimbursement for services as an in-network provider must undergo a process of credentialing. This process, otherwise known as primary source verification, is the process in which an insurance company verifies the provider's education, training, experience, and competency. In order to start this process, the provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty. Once the verifications are complete, the insurance company then decides if the provider meets their internal qualifications to serve as a provider of services to their insured members. After approval of a provider's credentialing file, the insurance company then issues a participating provider contract that allows the provider of services to bill the insurance company and receive reimbursement as an in-network provider of services. Failure to complete the insurance credentialing process will result in the provider being paid as out-of-network for services rendered