As a physician or other healthcare provider, you must apply for initial medical credentialing and be re-credentialed every 2-3 years, depending on the state in which you live and the policies of your payers. It’s a monumental task, but a necessary one, as it’s required before a healthcare organization or practice can bill on your behalf.
Medical credentialing can be a time-consuming process and can take up to 4 months to complete due to the requirement for submission of extensive background information – and that’s assuming you haven’t made any mistakes on the form. Additionally, and in the case of a new practice, the clinic or healthcare organization you’re working for may also need to be credentialed.
In years past, every healthcare provider had to be individually credentialed with each insurance plan. Many health insurance companies now use a centralized database to speed the process. Some physician specialists may be exempt from the re-credentialing process if they practice exclusively within a hospital setting, and in cases where a health plan does not have an additional need to review the physician’s credentials.
To save a little time in the credentialing process, review this list of the documents which are typically requested. Some plans may ask for additional material.
Documents checklist for medical credentialing:
- Personal information like email address, street address, phone, etc.
- Recent photograph signed and dated in the margin.
- Medicaid number.
- Medicare number.
- Copy of National Provider Identifier (NPI#) documentation and confirmation letter.
- UPON number.
- Federal Tax ID number.
- Copy of current Federal DEA and current State Controlled Substance Registrations or certificate(s).
- Copy of current driver’s license or passport.
- Permanent Resident Card, Green Card or visa status (if applicable) All non-US citizens must provide a copy of their green card.
- Copy of medical school diploma and training certificate(s), internship, residency and fellowship certificates.
- Current CME (CME activity for the past three years).
- Copy of current Board Certificate, including the name of issuing board and dates of board certification/recertification.
- Copy of all current active state license wallet card(s) and wall certificate with expiration date and number.
- Current Curriculum Vitae with complete professional history in chronological order and no gaps (month and year must be included).
- Current hospital and facility affiliations.
- Completed Delineation of Privileges Form.
- Work history including all practice locations and employment affiliations.
- Any disciplinary actions, including explanations.
- Malpractice claims history with details.
- Certificate of Professional Liability Insurance Coverage or declaration page (face sheet) of policy (if applicable).
- Third-party documentation (i.e. court documents, dismissals) for all malpractice/disciplinary actions OR completion of appropriate explanation form (if applicable).
- Three written letters of recommendation from providers who have directly observed you in practice within the past year (They must assess your clinical competence and specify the date they last observed you in practice by month and year).
- Military discharge record – Form DD-214 (if applicable).
- Copies of current immunization records and most recent TB test results (if available).
- Case log from the last 24 months (if applicable).
- Mammo #s and MQSA (if applicable).
- Copy of NBME, FLEX, USMLE, or SPEX scores.
- Copy of Any: BLS, ACLS, ATLS, PALS, APLS, NRP certificate(s).
- Completed Locum Tenens Practice Experience Form (if applicable.
- If a foreign graduate, your ECFMG certificate number and info on Fifth Pathway.