In the healthcare space, provider credentialing is the process that ensures physicians are qualified to perform medical procedures. It is critical because it saves both the healthcare facility and the provider from penalties due to malpractice or negligence.
However, it is a complicated and time-consuming process that requires you to submit many documents that may be difficult to track. Therefore, we have penned this physician credentialing checklist to help you speed up the process.
Wait a minute! Before we dive into it, it is crucial that you understand why we are emphasizing the importance of physician credentialing and dedicating an entire guide to it.
First of all, if you properly follow the credentialing process, it will help you optimize your medical billing and coding workflow, preventing payment delays and improving your practice’s overall revenue cycle management.
Physician Credentialing Checklist
The US has 50 states, each with its own set of rules and regulations when it comes to healthcare provider credentialing. Therefore, the initial step in credentialing should be to check your state laws. Besides, it is a time-consuming process requiring you to submit a series of documents and may take anywhere around 90-150 days to complete.
So, if you are a new provider looking to start your career, we recommend you start at the earliest. Here’s a breakdown of the stages required to complete your credentialing process:
Stage # 1 – Submitting the Pre-Application
The pre-application stage is sort of a background check of the physician that covers areas such as:
- Criminal records
- Disciplinary actions history
- Board certification
These steps help the credentialing board filter out ineligible/ unqualified providers. Besides, they may ask healthcare providers to submit additional documents in case of issues or concerns. But, don’t worry. If you are a qualified physician, no flags will be raised and you will easily pass this stage to move to the next one.
Stage # 2 – Submitting the Application
At this stage, you are required to submit the official application for credentialing. It mandates you to provide all the necessary information, supported by documents and copies. The required documents vary based on whether you are a physician, a nurse, a provider assistant, or a group.
Therefore, we will not complicate it and provide you with a detailed checklist of the required documents later in this guide. So, don’t leave, and continue reading till the end to uncover the information, or you can simply skip to that part.
Stage # 3 – Verification of Receipt
Once you submit the official credentialing application, we recommend that you proactively follow up to confirm its receipt with a call or an email. At this stage, the board may contact you, asking for further details. You must promptly provide this information to avoid delaying this process.
Besides, it is a good practice to keep a copy or two of the application and all the documents you submitted.
List of Credentialing Documents Required From New Physicians
If you are a new physician, looking to start practicing then you must follow the new provider credentialing checklist mentioned below:
- ACLS/BLS certification
- Case logs from the last twenty-four months (if applicable)
- Certificate of professional liability insurance coverage or declaration page of policy (if applicable)
- Complete work history with all employment affiliations and practice locations
- Completed locum tenens practice experience form (if applicable)
- Copies of current immunization records and most recent TB test results (if available)
- Copy of all current active state license wallet cards
- Copy of any NRP, ACLS, ATLS, BLS, APLS, or PALS certificates
- Copy of current board certificate, with issuing board details and board certification/recertification dates
- Copy of current state-controlled substance registrations or current federal DEA
- Copy of FLEX, NBME, SPEX, or USMLE scores
- Copy of medical school diploma, internship, training certificates, residency, and fellowship certificates
- Copy of NPI confirmation letter and documentation
- Copy of wall certificate with expiration date and number
- Current CME (CME activity for the past three years)
- DEA certificate
- Driver’s license
- Federal tax ID number·
- Green card, permanent resident card, or visa status for non-US residents
- Hospital privileges documents
- In the case of foreign graduates, the ECFMG certificate number and information on Fifth Pathway
- Last ten years’ insurance claims report
- Malpractice claims history with details
- Medicaid number
- Medicare number
- Military discharge record – form DD-214 (if applicable)
- MQSA and Mammo numbers (if applicable)
- Physician’s personal details, such as contact information, etc.
- Privilege form completed delineation
- Residency diploma
- Signed and dated recent photograph
- Social security card
- Surgical logs
- Third-party documentation (i.e., dismissals, legal documents) for all disciplinary/malpractice actions or completion of appropriate explanation form (if applicable)
- Three written recommendation letters from healthcare providers who have directly observed the candidate in a healthcare facility within the past year, assessing clinical competence with dates
- Updated CV with a complete professional history in chronological order and no gaps with month and year against each entry
- UPON number
List of Credentialing Documents Needed From Advanced Practice Registered Nurses and Physician Assistants
If you are an advanced practice registered nurse or a physician assistant (PA) then you may find the credentialing checklist similar to the provider’s with a few exceptions.
- An ongoing professional practice evaluation
- Case logs from the last 24 months (if applicable)
- Completed locum tenens practice experience form (if applicable)
- Copies of most recent TB test results and current immunization records (if available)
- Copy of all current active state license wallet cards
- Copy of college/university diploma and training certificates
- Copy of current federal DEA and state-controlled substance registration certificates
- Copy of NPI confirmation letter and documentation
- Copy of wall certificate with expiration date and number
- Current CME (past three years activity)
- Diploma and transcripts
- Driver’s license
- Federal tax ID number
- Focused professional practice evaluation
- Green card, permanent resident card, or visa status for non-US residents
- Immunization records
- Medicaid number
- Medicare number
- Military discharge record, form DD-214 (if applicable)
- Personal details, such as address, phone number, etc.
- Practice history with employment affiliations and facility locations
- Privileges form’s complete delineation
- Recent nurse/physician assistant signed and dated photograph
- Social security card
- Three professional recommendation letters
- Updated CV with complete professional history in chronological order with month and year
List of Credentialing Documents Needed From a Group Practice
Now, that we have discussed the provider credentialing checklist and required documents for PAs and registered nurses, it is time to discuss the same for a group practice or group of physicians.
When applying for credentialing as a group, each physician is required to submit their documents in a single application. Besides, each healthcare provider must fulfill the credential board’s requirements for the group to get accepted.
- Bank’s letter with the branch contact person’s name and phone number OR a voided check
- Commercial liability insurance of the group and for DME with NSC added
- Hours of operation specified from Monday to Friday and Saturday/Sunday
- Incorporation of the group articles
- IRS letter – CP575
- NPPES registry screenshot providing the group NPI
- Owner’s board certification (in case of a provider)
- Owner’s DEA license (in case of a provider)
- Owner’s medical degree certificate (in case of a provider)
- Owner’s copy of social security card or DL
- Owner’s social security number
- Start date of when the group started its operations
- W-9 form with the tax ID
Bottom Line
We hope the physician credentialing checklist we discussed will become a beacon of light for you and help you navigate the intricate credentialing process better. However, if you still find it overwhelming, you can outsource it to a professional company, like MediBill MD, offering credentialing services to healthcare providers, groups, certified nurses, and PAs.
Outsourcing the credentialing process is a smart strategy for providers and healthcare facilities alike because it is not an ongoing process. Physicians gain more knowledge, skills, and certifications over time and need credentialing to make them qualified to perform advanced procedures to avoid penalties.
Contrarily, healthcare facilities experience changes in their provider’s list and may be required to perform credentialing for their newly employed physicians and avoid payment delays.
