Re-credentialing

The periodic process, typically occurring every three years, in which a provider's credentials are re-verified to ensure they continue to meet the payer's or facility's standards for network participation.

Re-credentialing is the periodic review that payers conduct to make sure you still meet their standards for network participation. Think of it as credentialing all over again, but with the assumption that you have already been through the initial process. Most payers re-credential every two to three years. NCQA standards require it at least every 36 months. The payer will pull your CAQH ProView data again, re-verify your licenses and certifications, check for any new malpractice claims, look for sanctions or exclusions, and review your overall performance in the network. The re-credentialing process typically starts automatically on the payer's side. They will send you a notice that your re-credentialing cycle is coming up, and you need to make sure your CAQH profile is current and attested. If your profile is out of date or not attested, the process stalls, and you risk being dropped from the network. Getting terminated from a network because you missed re-credentialing is more common than people think, and the consequences are serious. Your existing patients would need to find a new in-network provider or pay out-of-network rates. You cannot bill for services rendered after your network participation lapses. Re-enrolling after a termination is harder and takes longer than maintaining continuous enrollment. The best approach is to track every payer's re-credentialing cycle and set reminders at least 90 days before each deadline. Make sure your CAQH attestation stays current, keep your malpractice insurance up to date, and respond immediately to any requests for additional information during the process.