What Is CAQH Credentialing?

If you work in the healthcare industry, then chances are you've heard of CAQH credentialing. The Council for Affordable Quality Healthcare (CAQH) is a nonprofit alliance of organizations that streamlines the business processes between healthcare providers and healthcare plans. In other words, it helps to make things run more smoothly between different organizations within the healthcare industry. Let’s take a moment to explore CAQH credentialing, how it works, and why it matters.

What Is CAQH?

CAQH formed in 2001 and currently has over 150 members representing both healthcare plans and providers. These members work together under CAQH CORE to identify opportunities for process improvement, automation and create solutions that benefit all parties involved. One of the ways CAQH does this is through credentialing.

Credentialing is the process of verifying that a healthcare provider meets certain standards and is licensed to provide high-quality care. CAQH credentials are primary source verified, which means that the information contained in a CAQH credentialing report comes directly from the provider themselves. CAQH data is used by hospitals for medical staff, health plans for provider enrollment, and other organizations during provider verification.

If a provider’s CAQH report checks out, the provider becomes qualified, eventually receives their credentials, and they can begin providing care. It's important to note that CAQH credentialing isn’t a one-time process. Instead, providers must maintain their information and re-attest that their data is current every 90-days to maintain their status.

How Does CAQH Credentialing Work?

It's important to make sure your provider credentials are up to date. This process can seem daunting at first, but it's actually pretty straightforward. For a provider to be credentialed, they must first complete an online application in CAQH Proview.

This application includes basic biographical information as well as details about their education, training, experience, licensure, work history, malpractice liability and current practice. Once the application is complete, the provider “attests” which submits their information to CAQH’s database. In turn, hospitals, health plans and State licensing boards are then able to query the provider’s information from CAQH when they receive a request to enroll the provider as a participating clinician or during recredentialing cycles. Reattestations by the provider insures CAQH data is complete and up to date.

The CMS Provider Enrollment, Chain, and Ownership System (PECOS) is an internet-based system that collects and stores data about healthcare providers who take part in Medicare. When a provider submits their CAQH application, they also authorize PECOS to release their Medicare enrollment details to CAQH.

Why Is Credentialing Important?

Credentialing is essential because it ensures patients receive high-quality care from licensed and qualified providers. It assures that providers meet basic standards and are up to date on the latest changes in their field. This protects patients by certifying that they’re only seeing providers who are qualified to provide the best care possible.

Credentialing also protects providers by guaranteeing that they’re only seeing patients who have been properly screened and approved for care by a health plan or healthcare organization. This helps reduce the risk of fraud and abuse while shielding providers from unwarranted malpractice lawsuits.

How Does CAQH Help with Credentialing?

CAQH simplifies the credentialing process by providing a central repository for provider data. This repository, CAQH Proview (formally known as the Universal Provider Datasource (UPD)), is used by over 1,000 organizations including health plans, hospitals, medical groups, and state licensing boards nationwide.

Proview contains over 20 million records on more than 1.6 million active providers nationwide. By using this resource, organizations can verify provider credentials quickly and easily, which saves time while also helping to ensure accuracy. In addition, because CAQH maintains updated records on such a large number of providers, organizations can rest assured that they're getting accurate information when they use Proview to credential healthcare providers.

Ask Us about CAQH Credentialing

CAQH credentialing is valuable for both healthcare providers and organizations that enroll them in insurance plans. By collecting and storing data in one central location, CAQH makes it easier for both groups to access accurate and up-to-date information about providers. If you have questions about how to get started with CAQH credentialing, then please don’t hesitate to give us a call or reach out online for support. We’ll gladly take the guesswork out of your credentialing process so you can focus on what you do best.