Provider Credentialing Checklist

Provider credentialing is an essential part of any healthcare organization. It ensures that the medical employees within the facility have all the needed qualifications and training to practice medicine and provide high-quality patient care. However, the process itself is quite complex and time-consuming due to the large volumes of information and documentation required. To ensure your credentialing process doesn’t get delayed due to a lack of necessary data, we’ve compiled a provider credentialing checklist for you to follow.

This way, you’ll be able to swiftly gather all the necessary information and finish the application without any issues that may prolong the process. Furthermore, we’ll highlight the importance of credentialing and elaborate on the process itself. Continue reading to discover all the essential documentation you’ll need for a straightforward provider credentialing process!

Understanding Provider Credentialing

Before we dive into the needed documentation related to provider credentialing, we first want to elaborate on its definition and use. As the name implies, this is a regulated process where healthcare organizations assess and verify the licensing and qualifications of their specialized medical providers. It applies to various types of healthcare personnel, including physicians, nurses, physical therapists, dentists, and other allied healthcare providers.

The main reason why provider credentialing plays a crucial role in healthcare organizations is because medical providers are responsible for the lives and well-being of patients. Thus, they obtain the required training and education to deliver proper patient care and services. Only by meeting the necessary standards and requirements set by regulatory and accrediting bodies, as well as insurance companies, are medical providers allowed to practice medicine on-site.

Remember that background checks on provider information, competency, and skill levels are essential for the legal operations of healthcare organizations and for ensuring patient safety. However, provider credentialing is also a mandatory standard set by the JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and the CMS (Centers for Medicare and Medicaid Services).

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Provider Credentialing Checklist–Overview

So, how does the credentialing process work exactly? While it’s generally known that medical credentialing is complex and time-consuming, its overview is quite straightforward. The main steps this process consists of are the following:

• Gathering necessary data and documentation: the first step is to gather all the required information about the provider’s training, licensure, qualification, and work experience. While it’s already complex to gather all the necessary documentation from multiple sources, you’ll also have to be mindful of any additional data relevant to the insurance industry. That’s why we always encourage our clients to double-check all the requirements before submitting their applications to prevent potential delays or denials.
• Verifying information: the next step is to review the gathered documentation and verify its legitimacy. Often considered the most difficult part of the process, this verification can be done manually or through the use of credentialing software. Furthermore, the data has to be verified through the primary source to avoid any inaccurate, outdated, biased, or falsified information.
• Awarding the credentials: lastly, if all the needed documentation is in order, the typical wait time for providers to get their credentials can be anywhere between 90 to 120 days.

Importance of a credentialing checklist

So, why is it so important to have a credentialing checklist at hand before an application? As mentioned, provider credentialing is a complex and time-consuming process. While the typical wait time to get your credentials is between 90 to 120 days, this timeframe can be delayed if you’re missing crucial paperwork. Thus, the already long waiting process will be further prolonged and may even result in a denial.

Another reason why many healthcare organizations rely on such checklists is to ensure they comply with regulatory requirements. Remember that provider credentialing falls under strict standards and regulations set by various regulatory bodies. Some of the most important ones are the following:

• Accreditation organizations such as the Joint Commission
• Government regulations provided by the Centers for Medicare and Medicaid Services
• Professional associations like the American Medical Association
• State licensing boards
• HIPAA (Health Insurance Portability and Accountability Act) compliance
• Insurance companies

To ensure the best results, it’s important for the documentation and information to have consistency and accuracy. Since medical personnel are subjected to ongoing monitoring and re-credentialing, such a comprehensive checklist will come in handy for future applications.

What Documents Are Needed for Provider Credentialing?

Provider credentialing comes with large volumes of documentation that you have to prepare beforehand. To ensure your application process is as smooth as possible, the main information you should focus on is the following:

• Personal information
• Professional Identification Numbers
• Tax and immigration documentation
• Licensure and certifications
• Malpractice and disciplinary history
• Professional experience and references
• Immunization and Health Records
• Continuing education

To make this checklist as detailed as possible, we’ll elaborate on each data separately.

Personal information

The first and easiest data to gather is the medical provider’s personal data. It gives an overall insight into the employee’s contact, location, and general information. That being said, the main information that should be included in such documentation is the following:

• First and last name
• Email address
• Street address
• Phone number
• Driver’s license
• Social Security card

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Professional identification numbers

The next data you should focus on are the provider’s professional identification numbers. This type of social identification describes the individual’s relations to their profession and their degree of expertise. Furthermore, they act as unique identifiers for various purposes, such as billing, credentialing, and communication within the healthcare system. They can be issued by different regulatory bodies, such as professional organizations, government agencies, and healthcare institutions.

The most important PINs for provider credentialing are the following:

• Medicaid number
• Medicare number
• National Provider Identifier (NPI#)
• UPIN number

Medicaid number

The Medicaid number is a unique identifier for practitioners who are part of a Medicaid program. This government-funded healthcare organization requires a unique Medicaid number that will be used as part of the credentialing process to verify the provider’s eligibility to participate in the program.

Medicare number

Similar to the Medicaid number, this unique identifier is used for those practitioners who want to take part in a Medicare program. While this number used to be based on the Social Security Number, it has evolved over time to have a similar function as the previously mentioned identification number.

National provider identifier (NPI#)

Used as another unique identification number for providers, the NPI falls under the HIPAA Administrative Simplification Standard. While its main purpose is to act as a standardized identifier for transactions and communication within the healthcare system, it also plays an important role in credentialing. These 10-digit numbers come in two types: one for medical providers and one for healthcare organizations. 

PTAN number

Short for a unique physician identification number, the PTAN number was used to identify doctors under the Medicare program. However, this six-character alpha-numeric element was replaced by the use of NPIs in 2007.

Tax and immigration documentation

The next step is to gather tax and immigration documentation. This paperwork is used to verify the medical provider’s eligibility to work within the country. Besides the regulatory bodies and healthcare organizations, tax and immigration documentation is also crucial for certain insurance companies to ensure that the providers meet their specific requirements regarding reimbursement and participation in insurance plans.

Depending on the provider’s legal status, the two types of documents you will need are:

• Federal T\tax ID number
• Permanent resident card or green card
• Visa status for non-U.S. citizens

Federal tax ID number

The Federal Tax Identification Number (FTIN), also called Employer Identification Number or Federal Employer Identification Number, is a unique number assigned by the IRS (Internal Revenue Service) or SSA (Social Security Administration). It consists of nine digits and is used for identification and tax purposes. It’s also a necessity when it comes to hiring employees and identifying healthcare organizations. 

Moreover, the healthcare industry uses TIN to report taxes and income, as well as comply with federal tax laws. When it comes to billing, this number can be used when submitting claims for reimbursement for services.

Permanent resident card or green card

For providers who don’t have U.S. citizenship, the provider credentialing process requires proof of either a permanent resident card or visa status. To better understand the use of each document, we’ll elaborate on each of them separately.

First, a permanent resident card, also called a green card, is an identification document that verifies the person in question has a permanent residency within the country. In simple terms, it acts as proof that you’re allowed to live and work within the U.S. With its name deriving from the card’s green color, each application is subjected to evaluation by the USCIS (United States Citizenship and Immigration Services) or BIA (Board of Immigration Appeals).

Even though the document gives the person a permanent residence within the borders of the country, it can still be deducted if they’re subjected to a criminal conviction. Thus, it plays a crucial role during the credentialing process to ensure proper patient safety and care.

Visa status for non-U.S. citizens

On the other hand, a visa status describes the legal permission of foreign nationals to enter and stay in the country as granted by the US government. The two types of visas within the US are Immigrant and non-immigrant. While the first allows the person to stay within the country permanently, the latter can only travel within the borders for a temporary period.

Since a non-immigrant visa acts as an entry document, it can expire while the person is still within the U.S. Thus, it’s important for regulatory bodies to assess the visa status to ensure that medical personnel are allowed to stay and practice medicine within the country.

Licensure and certifications

One of the most time-consuming documents you’ll have to acquire is licensure and certification information. Since healthcare providers are responsible for the well-being of real-life patients, they must show proof of the necessary education and training to practice medicine in their specific field. To better understand these documents, we’ll briefly elaborate on both of them.

Licensure is an official authorization for providers to practice medicine in their specialty. It’s granted by licensing boards or regulatory bodies. On the other hand, certification involves any additional credentials the provider has obtained by demonstrating their knowledge, specific skills, and practice areas.

To uphold professional standards, the documentation you’ll need is the following:

• Copies of all current active state license wallet cards and wall certificates with expiration dates and numbers
• Copy of current Federal DEA and State Controlled Substance Registrations or certificates
• Copy of medical school diploma, training certificates (internship, residency, and fellowship), and residency diploma
• Copy of current Board Certificate, including the name of the issuing board and dates of board certification or recertification
• Copies of BLS, ACLS, ATLS, PALS, APLS, and NRP certificates
• ACLS/BLS certification
• ECFMG certificate number and info on Fifth Pathway
• Copy of NBME, USMLE, FLEX, or SPEX scores

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Malpractice and disciplinary history

Often considered the most important information you should gather, it’s crucial to gather any evidence of malpractice and disciplinary history. This way, you will ensure the safety of your patients and prevent any issues from arising that may harm them. Furthermore, this documentation is used to evaluate the medical provider’s ethical behavior, professional conduct, and ability to deliver high-quality patient care.

To ensure you’ve gathered all the needed malpractice claims, disciplinary actions, lawsuits, and settlements, here are the most common information you’ll need: 

• Malpractice claims
• Third-party documentation for disciplinary actions
• Certificate of Professional Liability Insurance Coverage

Malpractice claims

The first documentation you need is a malpractice claims history. To ensure the provider is capable of delivering quality patient care, the paperwork has to elaborate on the claims with as many details as possible. Malpractice includes any professional misconduct or negligence that has resulted in any type of patient harm. Thus, these claims can be a result of various reasons, such as medication and surgical errors, misdiagnosis, and even failure to obtain informed consent. 

Since malpractice involves legal actions, it’s determined based on three characteristics. First, it must be a result of a treatment that’s not consistent with the standard of care. Next, the patient must have suffered from some injury under the provider’s care. Lastly, the injury must have had significant damages, like unusual pain and suffering, disability, or loss of income.

Third-party documentation for disciplinary actions

The next data you need to gather is any third-party documentation for malpractice or disciplinary actions. This includes court documents or dismissals relevant to the case and possible completion of an appropriate explanation form, if applicable.

Since disciplinary actions have formal sanctions, the process requires the regulatory body to note the actions in detail. This way, the accused medical provider has the opportunity to explain their actions and potentially resolve the matter. If the employee has actually violated the professional standards, regulations, or ethics, then the licensing board or regulatory agency will determine the right sanctions for them. Besides the common administrative penalties, these can include probation, license revocation or suspension, and fines.

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Certificate of Professional Liability Insurance Coverage

Lastly, you’ll need a Certificate of Professional Liability Insurance Coverage or a declaration page of the policy. This document is used as coverage proof and summarizes the necessary information about the provider’s professional liability insurance policy. Even though it’s not considered a legal document, it provides general information about the insurer, a description of operations, and coverage information. 

When it comes to insurance, some regulatory bodies also ask for a 10-year insurance claims report. Within this paperwork, the provider will disclose information about any accidents or incidents that may have occurred. This includes contact information about everyone involved in the incident, as well as the time and location of the accident. 

Professional experience and references

Next, you should gather all documentation related to professional experience and references. Similar to other work positions, this paperwork is used to evaluate the practitioner’s work capabilities. To ensure their suitability and competence for the desired work position, the main documents needed are the following:

• Work history that includes all practice locations and employment affiliations
• Delineation of Privileges Form
• Locum Tenens Practice Experience Form
• Case logs from the last 24 months (if applicable)
• Current Curriculum Vitae with complete professional history
• Three written letters of recommendation from medical providers who have observed the candidate in practice directly within the past year.
• Military discharge record – Form DD-214 (if applicable)

Immunization and health records

Another important aspect of provider credentialing is proof of immunization and health records. These documents give regulatory bodies access to the provider’s vaccination history to ensure they meet the required health and safety standards, as well as comply with regulatory requirements. Furthermore, such paperwork is needed to ensure patient safety and prevent any health risks regarding vaccine-preventable diseases. 

For that reason, the pain information required during provider credentialing is:

• Copies of current immunization records: to ensure that the medical provider’s vaccination history meets the standards, there has to be proof of the vaccines received, the vaccination status, and proof of immunity. This way, the healthcare organization reduces the risk of illness transmission within the healthcare setting. 
• Most recent TB test results: besides information about the provider’s past medical conditions, surgeries, and recent physical examinations, health records are also used to provide proof of screenings for infectious diseases. One such instance is tuberculosis testing, which is often required by regulatory agencies.

Continuing education

Lastly, if the medical provider has any ongoing training, you must include information about their continuing education. Since the medical industry is ever-evolving and new advanced technology is implemented in the practice, it’s important for medical providers to keep track of the latest trends. For that reason, the CME (Continuing Medical Education) consists of structured educational activities designed for medical practitioners to maintain, develop, or enhance their knowledge, skills, and professional competence. 

This education system is important for provider credentialing because it shows that the provider is willing to take the extra step to keep track of the latest medical advancements while also enhancing their skills and knowledge to improve patient outcomes and reduce clinical errors. 

Thus, some regulatory bodies may ask for current CME status or CME activity for the past three years. Whether it’s a specific number of credits or hours within a predetermined time frame, they can act as proof to maintain certain licensure and certification. Since medical providers can choose from various CMS activities, there are numerous workshops, conferences, online courses, and even self-directed learning modules they can try out.

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Conclusion

After reviewing this provider credentialing checklist, we hope it comes in handy for your next application process. Remember that this task is complex and time-consuming, so you should always take the time to organize all the needed documentation beforehand. This way, you’ll prevent any delays due to inadequate paperwork that may only prolong the already long process.

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