Credentialing
Credentialing is the process of verifying a provider’s qualifications so they can join a payer’s network or be granted privileges at a facility.
Updated
Credentialing is the verification of a healthcare provider’s qualifications — education, training, licensure, board certification, and work history — typically against primary sources. Payers and facilities require credentialing before a provider can participate in a network or treat patients at a site.
It is distinct from, and precedes, the steps that let a provider actually bill and be paid.
In practice
Credentialing is time-sensitive and gating: a provider who sees patients before credentialing and enrollment are complete generates claims that deny for enrollment reasons, so onboarding timelines must plan for the payer’s processing windows.
Commonly confused with
- Provider enrollment: Enrollment registers the credentialed provider with a specific payer so claims can be paid — a provider can be credentialed but not yet enrolled.
- Contracting: Contracting negotiates the payment rates and terms, separate from verifying qualifications.
- Privileging: Privileging grants a credentialed provider permission to perform specific procedures at a facility.