Credentialing Committee

A committee of healthcare professionals that reviews provider credentialing applications and makes formal decisions to approve, deny, or defer enrollment.

The credentialing committee is the group of people who actually decide whether you get credentialed or not. After your application is submitted, your documents are verified, and your file is complete, it goes before this committee for a formal vote. NCQA standards require that the credentialing committee include at least one physician. Most committees include several physicians representing different specialties, along with administrative staff from the payer's provider relations and credentialing departments. The committee chair is usually a medical director. The committee reviews your complete file, including all verification results, any discrepancies that were identified, malpractice claims history, sanctions, and the overall assessment prepared by the credentialing staff. They can approve you, deny you, defer your application pending additional information, or approve you with restrictions. Committees typically meet on a regular schedule, anywhere from weekly to monthly depending on the organization. If your application is complete and ready for review but the committee does not meet for another three weeks, that is three weeks of waiting that has nothing to do with you or your file. This is one of the hidden sources of credentialing delays that providers do not see. If your application is denied, you have the right to be notified of the denial and the reason for it. Most payers also provide an appeal or reconsideration process for denied credentialing applications. The appeal goes back to the committee with any additional information you provide. You almost never interact directly with the credentialing committee. Your communication is through the payer's credentialing or provider relations department. But knowing that this committee exists and meets on a schedule helps you understand why the process takes the time it does.