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For Providers: What Do I Need to Know About Credentialing and Recredentialing?

Credentialing is a verification process that proves you have the appropriate license, education, insurance and other qualifications necessary for your provider type.

It's also part of the process of joining our network and enrolling as a new provider. T he first thing you’ll do is fill out an enrollment form. Then we verify that the information submitted is accurate.

Our online provider enrollment is split into two sections: one for hospitals and facilities and one for physicians and professionals, also called practitioners. Here’s what you need to know about credentialing for each section.

For hospitals and facilities

We handle the credentialing process for hospitals and facilities. You’ll just need to fill out the appropriate enrollment form based on your facility type. Then make sure you review the required document checklist and provide all the necessary documentation along with any signature documents.

The checklist and signature documents are available online from within provider enrollment. When credentialing is complete, we’ll notify you of your status.

Recredentialing for hospitals and facilities

Hospitals and facilities are required to recredential every three years from the time they first join our network. Required forms need to include a signature and must be dated within 120 days of the request.

• Clinical independent laboratory
• Durable medical equipment supplier
• Freestanding Radiology Center
• Medicare-approved ambulatory surgical facility
• Medicare-approved physiological laboratory
• Urgent care center

For physicians and professionals

We use the Council for Affordable Quality Healthcare ® , or CAQH, to gather and coordinate the information needed for credentialing.

In addition to filling out our enrollment form, you’ll need to create a profile on CAQH ProView ® . We can’t complete credentialing without it.

Tips regarding enrollment

• Attestation must be completed within 14 days of submitting your enrollment form.
• New graduates can submit an enrollment form to us up to 60 days before finishing training.
• If you’re relocating from out of state, you can submit your enrollment form 30 days before your start date.

Tips regarding CAQH ProView

• Complete your CAQH ProView application within 14 days after submitting your enrollment form.
• Make sure your attestation is up to date if you already have a CAQH ProView profile.
• Be careful when choosing your primary specialty in CAQH ProView because your choice determines whether you’re designated as a PCP or specialist for managed care networks, may affect the way your claims are processed and will appear in our online provider directories.

Recredentialing for physicians and professionals

You'll use CAQH ProView to recredential, also called reattestation. It's the process of logging in to CAQH ProView, updating your information if needed, and then attesting, or certifying, that all the information is correct. You're required to reattest every 120 days.

How can I check credentialing status?

Call us at 1-800-822-2761. Have these things handy for each provider listed on the enrollment form:

• NPI
• Group tax ID number or the last four digits of each provider's Social Security number
• The provider's primary address and phone number