The short answer
| Credentialing | Privileging | Payer enrollment | |
|---|---|---|---|
| Question it answers | Is this provider who they say they are, and qualified? | What may this provider do in this facility? | Can this provider bill this payer as in-network? |
| Who decides | The organization doing the credentialing: a hospital, health plan, group or CVO | A hospital or facility, through its medical staff and governing body | The payer: Medicare, a state Medicaid program or a health plan |
| What it produces | A verified credentials file and a decision | A list of granted clinical privileges | An active enrollment with an effective date, and IDs to bill with |
| How often | Initially, then on a recredentialing cycle | Initially, then at reappointment | Initially, then at recredentialing or revalidation |
Credentialing
Credentialing is the process of collecting and verifying a provider’s qualifications: license, DEA registration, education and training, board certification, work history, malpractice history and sanctions. The key verifications are done with the issuing source, which is primary source verification. The result is a file and a decision, usually by a credentialing committee or an authorized designee.
Hospitals, health plans, medical groups and credentials verification organizations (CVOs) all credential. Many health plans follow NCQA credentialing standards.
Privileging
Privileging is specific to hospitals and other facilities. After credentialing a provider, the facility decides which procedures and services the provider may perform there, based on their training, experience and competence. For hospitals in Medicare, the conditions of participation require the medical staff to examine the credentials of candidates and make recommendations to the governing body (42 CFR 482.22). Privileges are reviewed again at reappointment.
A provider can be credentialed by a health plan and never hold hospital privileges, for example a therapist in private practice.
Payer enrollment
Payer enrollment is the process of getting a provider set up to bill a payer. It differs by payer type:
- Medicare: enrollment through CMS, usually online in PECOS, processed by a Medicare Administrative Contractor. Medicare revalidates enrollment every five years, or three for DMEPOS suppliers.
- Medicaid: enrollment with each state’s Medicaid program, and often separately with the managed care plans that serve it. States revalidate at least every five years, some more often; see Medicaid revalidation by state.
- Commercial and managed care plans: the plan credentials the provider, often using their CAQH ProView profile, and loads them into its network once a contract is in place.
Where contracting fits
Contracting is the agreement between the practice (or provider) and the payer: rates, terms and the products covered. A provider can be credentialed by a plan but unable to bill as in-network because the contract is not signed or not loaded. When tracking enrollment, keep credentialing status, contract status and the effective date as separate facts.
How they connect
All three depend on the same verified credentials, so a lapse in one shows up in the others. An expired license can stop privileges, trigger a payer termination and lead to denied claims. That is why it helps to keep credentials, enrollments and billing in one place. Credentik tracks credentialing and PSV, payer enrollment and claims side by side.