Payer Credentialing Checklist: 10 Must-Haves

As a healthcare provider, navigating the complex world of payer credentialing can be daunting. However, a well-prepared application is crucial for ensuring timely reimbursements and maintaining a thriving practice. This comprehensive guide will walk you through the ten essential items you need for a successful payer credentialing application, helping you streamline the process and avoid common pitfalls.

1. Personal Information

  • Your application starts with the basics. Ensure you have the following personal details ready:
  • Full legal name
  • Date of birth
  • Social Security Number
  • Home address
  • Contact information (phone number and email address)
  • Pro tip: Keep a digital folder with scanned copies of your identification documents for easy access and quick submission.

2. Professional Information

  • Payers need to understand your professional identity. Be prepared to provide:
  • National Provider Identifier (NPI) number
  • Tax Identification Number (TIN)
  • DEA number (if applicable)
  • Medicare/Medicaid numbers (if applicable)
  • Did you know? According to the Centers for Medicare & Medicaid Services, over 3.9 million healthcare providers had active NPIs as of 2021. Ensuring your NPI is up-to-date is crucial for smooth credentialing.

3. Educational Background

  • Your education forms the foundation of your expertise. Include detailed information about:
  • Medical school name and graduation date
  • Residency program(s) and completion dates
  • Fellowships (if applicable)
  • Any additional relevant training or education
  • Remember to have official transcripts or diplomas readily available, as some payers may request copies for verification.

4. Work Experience

  • Showcase your professional journey with a comprehensive work history. Provide:
  • Names and addresses of all previous employers
  • Dates of employment
  • Positions held
  • Reasons for leaving (if applicable)
  • Tip: Maintain an updated CV that includes all your work experiences, making it easier to fill out multiple applications accurately.

5. Licenses and Certifications

  • Your credentials are paramount. Ensure you have up-to-date information on:
  • State medical license(s)
  • Board certifications
  • Any specialty certifications
  • According to the Federation of State Medical Boards, there were over 1 million actively licensed physicians in the U.S. as of 2020. Keeping your licenses current is essential for maintaining your credentialing status.

6. Malpractice Insurance

  • Proof of malpractice coverage is non-negotiable. Be ready with:
  • Current policy information
  • Coverage amounts
  • Policy expiration date
  • Tip: Set reminders for policy renewal dates to ensure continuous coverage and avoid credentialing delays.

7. Hospital Privileges

  • If applicable, provide details about your hospital affiliations:
  • Names and addresses of hospitals
  • Types of privileges held
  • Dates of affiliation
  • Remember, some payers may require you to have active hospital privileges as part of their credentialing criteria.

8. Professional References

  • Choose your references wisely. Prepare a list of:
  • At least three professional references
  • Their contact information
  • Your professional relationship with each reference
  • Pro tip: Inform your references in advance that they may be contacted, ensuring a prompt and positive response to credentialing inquiries.

9. Continuing Medical Education (CME)

  • Demonstrate your commitment to ongoing professional development:
  • List recent CME courses completed
  • Include dates and credit hours earned
  • According to the Accreditation Council for Continuing Medical Education, physicians completed an average of 31.8 CME hours in 2020. Staying current with CMEs not only benefits your practice but also strengthens your credentialing application.

10. Additional Documentation

  • Be prepared to provide supplementary information:
  • Current CV
  • Proof of COVID-19 vaccination (increasingly required)
  • Any relevant research or publications
  • Awards or recognitions
  • Tip: Keep a digital portfolio of your achievements, making it easy to highlight your expertise during the credentialing process.

By ensuring you have these ten essential items ready for your payer credentialing application, you’ll be well-prepared to navigate the process efficiently. Remember, thorough preparation not only expedites the credentialing process but also demonstrates your professionalism and attention to detail to payers.

We at TriumpHealth know there are lots of moving parts to the payer credentialing process.  We can help make sure they are all working for you!  Schedule a consultation with us today!