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In the absence of proper medical credentialing, the healthcare providers (hospital, physician office, dental practice, or surgery center and more) cannot work in any place and cannot partner with health insurance legally. As a result, reimbursement for medical services can also be denied or delayed and facility will have to face loss in revenues. Medical Credentialing is very crucial for both the patient and the healthcare providers because it ensures that service providers are competent to do the best and possible standers job.
Credentialing requirements vary state to state, county, and populations even medical facilities and insurance carriers. The major credentialing requirements include education and training, Hospital affiliation, State license(s), DEA license, Provider enrollment application, Board certification, Malpractice insurance certificate, Sanctions disclosure, Criminal background disclosure, Background Screening, Military service and IRS- Letter.
The departments for Verification are National Practitioner Data Bank (NPDB), American Board of Medical Specialties (ABMS), American Association of Nurse Practitioners (AANP) / American Nurses Credentialing Center (ANCC) and Student Clearing House.
|Administrative Services Organization (ASO)||Home & Community Based Services (HCBS)||Osteopath|
|Ambulatory Surgery Center (ASC)||Home Health||Personal Care Agency|
|Behavioral Therapy – Clinic||Hospital – General||Pharmacy|
|Behavioral Therapy – Individual||Hospital – Mental||Physical Therapist|
|Birthing Center||Independent Laboratory||Physician|
|Case Management Agency||Pharmacy||Physician Assistant|
|Certified Addiction Counselor (CAC)||Licensed Addiction Counselor (LAC)||Podiatrist|
|Certified Registered Nurse Anesthetist (CRNA)||Licensed Behavioral Health Clinician||Psychiatric Residential Treatment Facility|
|Clinic – Dental||Licensed Clinical Social Worker (LCSW)||Psychologist - Bachelors|
|Clinic – Practitioner||Licensed Marriage and Family Therapist (LMFT)||Registered Nurse|
|Community Clinic||Licensed Professional Counselor (LPC)||Rehabilitation Agency|
|Community Mental Health Center||Licensed Psychologist||Residential Child Care Facility|
|Dental Hygienist||Managed Care Organization (MCO)||Rural Health Clinic|
|Dentist||Non-Physician Practitioner - Group||School Health Services|
|Dermatologist or Dermatology Clinic||Non-Physician Practitioner – Individual||Speech Therapist|
|Dialysis Center||Nurse Practitioner||Substance Use Disorder - Clinics|
|Durable Medical Equipment (DME)||Nurse-Midwife||Substance Use Disorder - Individuals|
|Family Planning Clinic||Nursing Facility||Supply|
|Federally Qualified Health Center||Nursing Facility - ICF/IID||Transportation|
|Foreign Teaching Physician||Occupational Therapist||X-Ray Facility|
|Health Maintenance Organization (HMO)||Optometrist||Many More|