The Council for Affordable Quality Healthcare (CAQH) is an organization established by some of the largest health plans in the country. These health plans are still on the Board of Directors today.
According to the official CAQH provider guidance, the organization or Council was originally founded to reduce the burden providers face when exchanging credentialing information with multiple payers and to streamline the process into a single submission.
Importance of CAQH for Providers & Organizations
The CAQH Provider Data Portal (formerly known as CAQH ProView), as mentioned, is the primary resource for self-reporting professional and practice information to payers.
It can also be used to share practitioner information with:
- Hospitals
- Large provider groups
- Health systems
According to the CAQH Provider Data Portal User Guide (Version 43, last updated August 22, 2023), professionals can eliminate duplicative paperwork when submitting credentialing packages to multiple insurance payers simultaneously. They can create their provider profile and submit information through the CAQH portal. This information is used for:
- Claims administration
- Credentialing
- Directory services, and more.
What Does the CAQH Database Look Like?
The published figures from CAQH suggest the portal provides information on more than 4.8 million providers. Additionally, over 2.5 million professionals have confirmed their data within the last 120 days, proving the level of compliance and activity on the platform.
Moreover, healthcare providers have the option to connect with 1,000 health plans and healthcare organizations. These organizations review the provider data for:
- CAQH credentialing
- Network management
- Referrals
- Provider directories
- Health equity initiatives, etc.
CAQH reports that nearly 80% of MDs, DOs, and DMDs within the U.S. upload and share their professional information through this platform.
CAQH: The Portal for Providers
One of the primary reasons why providers rely on the platform is that it is free of charge. Instead, organizations pay to access provider data through the platform’s commercial solutions.
During the process, a single CAQH credentialing application is generated through the portal. This application is widely accepted across all 50 U.S. states, including those with specialized regulatory requirements.
What’s more? The system receives regular updates that reflect new state/ federal laws and requirements as they are announced. Additionally, compliance is a vital component, as the platform collects and compiles information aligned with standards set by organizations such as:
- National Committee for Quality Assurance (NCQA)
- Utilization Review Accreditation Commission (URAC)
- The Joint Commission (formerly JCAHO)
Note: The platform also complies with HITRUST CSF best-in-class data protection standards, which ensure all provider information remains safe from cyberattacks and breaches.
CAQH Credentialing Application Process
Based on the CAQH Provider Data Portal User Guide, the initial CAQH profile creation process consists of six structured steps. On average, providers spend up to two hours on the initial CAQH credentialing application. However, the actual time for application may differ based on:
- Practice locations
- Amount of postgraduate training and work history
- Provider’s familiarity with online tools
The following is a comprehensive breakdown of these steps for your understanding:
Step 1: Platform Registration
The first step is to initiate registration through the official website at proview.caqh.org. New registrants who receive an invitation from a health plan get a pre-assigned CAQH Provider ID.
On the other hand, self-registering healthcare providers receive a CAQH Provider ID via email after submitting initial account details.
The User Guide suggests that registrants wishing to create an account must provide the following information.
- NUCC grouping
- Provider type
- Full legal name
- Home address
- Primary practice state
- Date of birth
- Email address
- Social Security Number (SSN)
- National Provider Identifier (NPI)
- DEA Number
- License state
- License number.
Note: Providers without an NPI, DEA, or license number check the relevant box during registration to indicate they don’t have them.
For Multiple Provider Practices
CAQH also offers a Practice Manager Module, through which a clinic administrator can provide shared data one time for several payers. This prevents duplicate entries for each payer and saves time.
Through this option, practice administrators manage delegated location data and rosters for existing providers enrolled within a centralized solution.
Step 2: Application Completion
As mentioned in the Provider User Guide Version 43, the CAQH profile involves the following sections:
| Section | Description |
|---|---|
| Core Provider Details | Full name, current address, and contact information. |
| Professional Identifiers | NPI, DEA, SSN, Medicare/Medicaid IDs, and state license numbers. |
| Education and Clinical Training | Medical school, internships, residency, fellowship, and other training. |
| Areas of Specialization | Primary and secondary specialties based on NUCC taxonomy. |
| Employment and Work History | Complete record of current and past professional roles. |
| Practice Location Details | Office addresses, hours, services, billing info, and accepted health plans. |
| Hospital Affiliations and Privileges | Admitting privileges, arrangements, and non-admitting affiliations. |
| Professional Liability Coverage | Insurance carrier, policy number, coverage limits, effective/expiry dates. |
| Professional References | Peer or supervisory references. |
| Credentialing Contact Information | Designated individual responsible for credentialing communication. |
| Disclosure Statements | Yes/No for licensure issues, malpractice, or sanctions. |
Step 3: Data Review For Accuracy
Once the providers have updated all the requested information, the review screen appears, allowing any errors to be corrected before submission. This review allows professionals to view a full printable summary of their CAQH profile.
Moreover, professionals can also generate a state-specific application copy from the portal to match the state-level CAQH credentialing requirements.
Step 4: Provide Payer Access to Profile
After the accurate data has been reviewed, providers have the freedom to select the insurance payers permitted to view their CAQH profile. This authorization is 100% provider-controlled. So, unless a payer has the provider’s explicit approval, it cannot view the details.
As per CAQH’s FAQs section, healthcare providers can also update the payers and organizations that can access their profile (whenever needed) via the authorize function available on the portal.
Step 5: Profile Attestation
Data accuracy holds utmost importance for CAQH credentialing. Thus, providers must declare that all the profile information is complete and 100% accurate. Typically, this is done through profile attestation.
According to the official policy:
- Providers must re-attest after 120 days.
- The attestation must be repeated every 180 days for Illinois providers to meet credentialing requirements.
- The CAQH also recommends updating data every 90 days to ensure the most recent data is available on the portal.
- Violating these rules changes the provider’s CAQH profile status to Expired, limiting the health plan’s access to the provider’s profile for credentialing. This can only be resumed after the provider completes re-attestation.
Step 6: Supporting Document Upload
Providers must also upload documents to support the entered information. These documents include (but are not limited to):
- State medical licenses
- Training certificates
- DEA certificates
- Professional liability insurance (PLI) documentation.
- A signed Authorization, Attestation, and Release (AAR) Form
Note: the AAR is applicable for specific states, including:
- North Carolina
- Oklahoma
These states require additional documentation, which providers can find on the portal.
Key Benefits of CAQH Credentialing
CAQH credentialing offers dedicated benefits for both providers and payers. The following is a comprehensive breakdown, covering benefits for both.
For Providers
The CAQH Provider Data Portal assists practices by eliminating redundant credentialing submissions. Before the introduction of CAQH credentialing, a provider enrolling and contracting with multiple health plans had to submit a separate application for each payer.
Due to this repetitive work and inefficiency, physicians were spending approximately $2.76 billion annually. Fortunately, with the CAQH database, information is entered only once and shared with multiple authorized payers and organizations with a single click.
Widely Accepted in All 50 States
The credentialing application generated after registering on the CAQH is widely acceptable in all 50 states, even the ones with specific state requirements.
Access to CAQH University
Registration on the portal provides access to CAQH University, which helps you learn interface use, drastically reducing the learning curve involved.
Centralized Document Storage
All documents uploaded on the CAQH profile are stored in a secure location and can be accessed by authorized payers or parties anytime.
Free Access
The portal is 100% free for providers. However, health plans are required to pay to view the available data.
Multi-provider Management
The portal’s interface allows professionals to manage multiple providers in one place, significantly reducing administrative overhead.
Reminders for Re-attestation
Professionals receive email reminders when their re-attestation nears. It reduces the likelihood of profile expiration or credentialing workflow disruption.
For Payers
Did you know that the CAQH credentialing portal has 1,000+ health plans and healthcare organizations registered with it? The key payer-related benefits are as follows:
Sanctions Monitoring
CAQH offers a Sanctions Monitoring feature that flags sanctioned providers daily. It can be used to monitor:
- License actions
- Sanctions
- Medicare/Medicaid exclusions
Compliance Infrastructure
Since the portal complies with several official organizations, like NCQA and URAC, CAQH-derived data can be trusted for credentialing workflows.
No Repeated Outreach Requests
Providers enter the data once on the platform, and themselves select the payers and organizations that can access this information. So, all that the payers have to do is access the provider’s CAQH profile and retrieve the information required for credentialing, without sending separate requests.
Primary Source Verification (PSV)
The PSV solution available on the portal reviews and verifies all the information against licensing boards and medical schools to ensure greater accuracy, better speed, and additional control for credentialing decisions.
CAQH Credentialing Challenges for Providers
Undeniably, the CAQH Provider Data Portal has improved efficiency and centralized data access. However, certain operational challenges persist that providers should remain mindful of. These obstacles include:
Time-Intensive Initial Application
Official sources suggest the initial portal sign-up can take up to two hours per provider. Moreover, providers with multi-location practices or detailed histories may have to spend longer.
Similarly, for less familiar professionals (or those using the tool for the first time), the estimate is much higher.
Moreover, practices require a much higher administrative investment if they onboard multiple partners.
Compliance Risk from Mandatory Re-Attestation
The portal mandates a 120-day re-attestation requirement, and if a provider fails to follow their state-specific period, their CAQH profile status changes to “Expired”, limiting data access until successful re-attestation.
This can affect the provider’s visibility. Thus, providers must ensure proactive monitoring of their profiles.
CAQH Not a Complete Substitute for Every Payer
A CAQH profile is well-supported in all 50 states, with 1,000 insurance payers and health systems participating in it. However, none of the organizations use CAQH as their sole information source to view provider details.
For instance, Medicare Advantage plans may use it as a supplemental source to PECOS for credentialing applications.
Therefore, providers must verify whether the payer accepts CAQH as a primary or supplemental credentialing source.
Extra Burden on Rural Providers
CAQH’s industry insights indicate rural providers face extreme administrative burdens because of CAQH credentialing issues.
The reason? Rural practices typically have smaller support teams, rely heavily on manual processes, and have less access to specialists.
All of these factors make it more time and resource-intensive to maintain a CAQH profile. These challenges are amplified for multi-provider or multi-location practices.
Disclosure Section Review
The disclosure section on the CAQH credentialing platform requires providers to answer questions with yes or no responses. These questions can be regarding their:
- License history
- Malpractice claims
- Sanctions
- Other professional conduct matters
If providers submit inaccurate or inconsistent disclosures, it can lead to:
- Delays
- Additional review
- Unfavorable credentialing decisions
Thus, providers should review the disclosure questions carefully or, better yet, consult a legal counsel before providing the information.
Simplify CAQH Credentialing With MediBillMD
Managing CAQH profiles and tracking re-attestation deadlines requires a deep understanding of the portal. Thus, practices with inadequate credentialing staff may face additional challenges.
Fortunately, MediBillMD’s medical credentialing services are designed to manage the credentialing lifecycle for providers in its entirety. You can entrust your CAQH credentialing to them and enjoy hassle-free payer enrollment and contracting.
Frequently Asked Questions
