Credentialing Application

The formal application submitted by a healthcare provider to a payer or facility requesting enrollment in their provider network, containing all required professional and personal information.

The credentialing application is the document that kicks off the entire enrollment process. It asks for everything about you: personal identification, education, training, licensure, board certification, work history, malpractice claims history, criminal history, hospital privileges, references, and attestation questions. Most payers accept CAQH ProView as their credentialing application. When you authorize a payer to access your CAQH profile, that serves as your application. The payer pulls your data and begins the verification process. This is why keeping your CAQH profile complete and attested is so important. An incomplete CAQH profile is an incomplete application. Some payers still require their own proprietary application forms in addition to or instead of CAQH. Medicare uses the CMS-855 family of forms through PECOS. Some state Medicaid programs have their own portals. A few commercial payers have supplemental forms that ask for information not captured in CAQH. The biggest mistakes on credentialing applications are gaps in work history, inconsistent dates, and incomplete attestation answers. Payers scrutinize work history gaps because they want to know what you were doing during any period when you were not practicing. A six-month gap between residency and your first job needs an explanation, even if you were just on vacation or studying for boards. Date inconsistencies cause delays. If your application says you started at a practice on March 2022 but your hospital privileges application says January 2022, the payer will ask you to clarify. Double-check every date on your application against your CV, license records, and other submitted documents. Attestation questions about malpractice, disciplinary actions, and criminal history must be answered completely and honestly. A "yes" answer does not automatically disqualify you, but a failure to disclose something that shows up during verification is a much bigger problem. Review the questions carefully and when in doubt, disclose and explain. Save a copy of every application you submit, including the date submitted and confirmation number. You will need to reference previous applications when filling out new ones.