Understanding the Broad World of Credentialing

Doctor with credentials on wall behind himThere are different types of credentialing in the medical world, making the word “credentials” a very broad term. For instance, a physician needs to have insurance credentials in order to be a provider for different insurance companies. They have to have the proper credentials for each insurer whose patients they want to treat.

However, credentials also involve the licenses, certificates, and other items that are needed to show that a physician is truly a physician allowed to practice in their particular area. It seems as if there are credentials that are needed for virtually anything and everything. This is why many physicians hire a credentialing specialist to take care of their physician credentialing. That way the physician is not spending their time filling out forms when they need to be treating patients.

Key Points to Keep in Mind

In the U.S., there are local, state, national, and professional organizations that establish the credentials that physicians need to treat patients. Here are some things to keep in mind:

  •  There is no standardized, national system for credentialing some types of health practitioners. It is up to the state and local governments to decide what credentials are needed to work within their areas.
  • Insurance companies require that physicians complete all of the necessary steps their company requires to be able to treat patients carrying their insurance.
  • Physicians have to become properly credentialed to be able to accept Medicare and Medicaid.
  • A professional physician credentialing consultant will be able to review the requirements and steps that need to be completed to achieve specific credentials and can carry out the process for you.

Credentialing, Licensing, and Certification

States have medical boards that oversee physicians within the state. This is why physicians need to be licensed to practice in the states that they wish to practice in. This is somewhat different than other types of credentialing. The physician will need to apply for a license in the state they wish to practice and complete the necessary steps. A consultant is useful in this situation as well. From there, the physician may need to provide information about their education and experience to a state consumer protection agency.

The requirements of each state in granting a license can vary a great deal. Of course, a physician must graduate from medical school, but they may also have to meet certification requirements of a national organization, have a certain amount of training under their belt, pass written exams when required, and also engage in personal education so that they are always up-to-date in what is happening in their field.

Credentialing Requirements

For physicians to become credentialed in virtually any area, they have to have a valid and current license, clinical privileges at a hospital, valid DEA certificate, the appropriate education and training, board certification, a satisfactory work history, malpractice insurance, and make available their history of liability claims. These are just some of the standard requirements of organizations and other entities that physicians may seek credentials for.

The application process typically follows this path:

  • The application must be completed and a statement may need to be provided that covers the applicant’s ability to perform the essential functions of their position, if there has been any illegal drug use, if there has ever been a felony conviction or loss of license, if there has ever been any disciplinary activity or limitation of privileges, and that the application is correct. The statement is used to explain any of the problems that may have come about in the past. Your physician credentialing consultant can help you with this process.
  • The application is then reviewed to determine completeness. If it is complete and the basic qualifications are met, then it is forwarded to the appropriate individual who then reviews it to determine if a preliminary interview should be conducted. Credentials through primary sources are also verified.
  • New providers may receive a visit to their office where a number of elements will be evaluated.
  • The validity of the license, DEA certificate, and the history of professional liability will most likely be reviewed.
  • Depending on the organization, a file is prepared for the credentialing committee.
  • All of the required data elements will be entered into the credentialing file.
  • The decision is then made to approve or reject the physician’s application for credentialing with the organization or entity.
  • Recredentialing will need to occur after an amount of time specified by the insurance company, organization, or other entity.

All in all, credentialing is necessary and a first step for new practitioners. It can also be a step in the right direction for those that have been practicing for a while. This can enable you and your practice to be everything you want it to be in your community.


If you wish to achieve credentialing with insurance companies, Medicaid and Medicare, or with an organization or other entity, MD Pro Solutions can help you. To learn about how our credentialing specialists can make the task easier for you and help you obtain as many credentials as you need, call us at 508-946-1665 or fill out our contact form.