Resource Center
Credentialing Glossary
Definitions for every credentialing, enrollment, and compliance term you need to know — from A to Z.
Accreditation
Formal recognition by an authorized body, such as NCQA or URAC, that a healthcare organization meets established quality standards and best practices...
Appeal
A formal request by a provider or patient to an insurance payer to reconsider a denied claim or coverage decision, providing additional documentation...
Attestation
A formal written statement by a provider affirming the accuracy and completeness of their credentialing application, including declarations regarding...
Audit
A systematic review and examination of a provider's or organization's records, processes, and compliance with credentialing standards, regulatory requ...
BAA
A Business Associate Agreement is a required HIPAA contract between a covered entity and a business associate that establishes permitted uses and disc...
Board Certification
A voluntary credential earned by a physician who has completed residency training and passed a rigorous specialty exam administered by an ABMS member...
CAQH
The Council for Affordable Quality Health Care, an organization that maintains a universal provider database (CAQH ProView) used by most health plans...
Clean Claim
A healthcare insurance claim that is submitted with all required information, correct coding, and proper documentation, allowing the payer to process...
Coinsurance
The percentage of costs for a covered healthcare service that a patient pays after meeting their deductible, with the insurance plan paying the remain...
Compliance Officer
A designated individual within a healthcare organization responsible for developing, implementing, and monitoring the organization's compliance progra...
Copay
A fixed dollar amount that a patient pays at the time of receiving a covered healthcare service, with the insurance plan covering the remaining cost....
Covered Services
Healthcare services and procedures that are included in an insurance plan's benefits, meaning the payer will reimburse all or part of the cost when re...
Credentialing
The process of verifying a healthcare provider's qualifications, training, licensure, and professional background to ensure they meet the standards re...
CVO
A Credentials Verification Organization is a third-party entity that performs primary source verification of provider credentials on behalf of health...
DEA
The Drug Enforcement Administration registration is a federal license that authorizes healthcare providers to prescribe and dispense controlled substa...
Deductible
The amount a patient must pay out of pocket for covered healthcare services before the insurance plan begins to reimburse. Deductibles reset annually...
Delegated Credentialing
An arrangement where a health plan delegates the credentialing process to a qualified healthcare organization, such as a hospital or CVO, that meets t...
Denied Claim
A healthcare claim that has been reviewed and rejected by an insurance payer due to errors, missing information, lack of coverage, or failure to meet...
ECFMG Certification
A certification from the Educational Commission for Foreign Medical Graduates required for international medical graduates who wish to enter graduate...
EPO
An Exclusive Provider Organization is a managed care plan similar to a PPO but with no out-of-network coverage except in emergencies, requiring member...
Explanation of Benefits
A statement from an insurance payer sent to the member after a claim is processed, detailing the services billed, the amount covered, the provider's a...
Grievance
A formal complaint filed by a member or provider regarding dissatisfaction with the quality of care, access to services, or the administrative process...
Group Practice
A medical practice in which multiple healthcare providers share administrative resources, facilities, and often a group NPI number, and may be credent...
HIPAA
The Health Insurance Portability and Accountability Act is a federal law that establishes national standards for protecting sensitive patient health i...
HMO
A Health Maintenance Organization is a managed care plan that typically requires members to choose a primary care physician and obtain referrals for s...
Malpractice Insurance
Professional liability insurance that protects healthcare providers against claims of medical negligence or errors, covering legal defense costs and p...
Managed Care
A healthcare delivery system organized to manage cost, utilization, and quality through techniques such as provider networks, referral requirements, a...
Medical License
A state-issued authorization that permits a physician to practice medicine within that state's jurisdiction, obtained by meeting education, examinatio...
NCQA
The National Committee for Quality Assurance is an independent organization that accredits and certifies health plans and CVOs, and sets the gold stan...
Network Status
A provider's participation status with a specific insurance payer, indicating whether they are in-network (contracted) or out-of-network (non-contract...
NPDB
The National Practitioner Data Bank is a federal repository of reports on medical malpractice payments, adverse licensure actions, adverse clinical pr...
NPI
The National Provider Identifier is a unique 10-digit identification number issued by CMS to healthcare providers, required for all HIPAA-standard adm...
OIG Exclusion
A determination by the Office of Inspector General that a provider is excluded from participation in all federal healthcare programs, meaning no feder...
Out-of-Network
A healthcare provider who does not have a contract with a particular insurance payer, meaning patients may pay higher out-of-pocket costs and the prov...
Participating Provider
A healthcare provider who has signed a contract with an insurance payer to provide services to the plan's members at negotiated rates, also known as a...
Payer
An insurance company, health plan, or government program (such as Medicare or Medicaid) that reimburses healthcare providers for medical services rend...
PHI
Protected Health Information is any individually identifiable health information created, received, maintained, or transmitted by a covered entity or...
POS
A Point of Service plan is a managed care plan that combines features of HMOs and PPOs, requiring a primary care referral for specialists but allowing...
PPO
A Preferred Provider Organization is a managed care plan that offers a network of contracted providers at lower costs to members, while still providin...
Premium
The periodic payment made by or on behalf of a member to maintain health insurance coverage, typically paid monthly regardless of whether healthcare s...
Prescriptive Authority
The legal authorization granted to a healthcare provider, such as an NP or PA, to prescribe medications. Requirements vary by state and may include co...
Primary Source Verification
The process of verifying a provider's credentials directly from the original issuing source, such as medical schools, licensing boards, and certificat...
Prior Authorization
A requirement by an insurance payer that a provider must obtain approval before delivering certain services, procedures, or medications in order for t...
Privileges
The specific clinical services and procedures a healthcare provider is authorized to perform at a particular healthcare facility, granted based on the...
Provider Enrollment
The process by which a healthcare provider applies to participate in an insurance payer's network, allowing the provider to bill and receive reimburse...
Sanctions
Disciplinary actions taken against a healthcare provider by a licensing board, government agency, or professional organization, which can include fine...
Solo Practice
A medical practice owned and operated by a single healthcare provider who is independently responsible for all administrative, clinical, and credentia...
State License
A professional license issued by a state regulatory board that authorizes a healthcare provider to practice their discipline within that state, subjec...
Superbill
An itemized form used by healthcare providers to document the services provided during a patient visit, including diagnosis codes and procedure codes,...
Taxonomy Code
A unique 10-character alphanumeric code assigned to healthcare providers that classifies their specialty, subspecialty, and provider type for use in e...
Telemedicine
The delivery of healthcare services remotely using telecommunications technology, which may require separate state licensure and specific payer creden...