What Makes a Credentialing Application Compliant?

Having a compliant credentialing application is important because it means that a practitioner is abiding by a health plan or organization’s requirements. Practitioners must have compliant credentialing applications to join a health plan or organization's network. The NCQA (National Committee for Quality Assurance), a nationally recognized nonprofit organization that aims to improve healthcare quality, has determined a compliant credentialing application has four elements:

Attestation:

• Practitioners must attest to the accuracy of the application and the attestation may not be over 120 days old.

Work history:

• Include 5 years of work history in the work history section of your application, or, if you have worked less than 5 years, we will need work history from date of initial licensure
• Provide a complete work history in the work history section of your application - any gaps in employment greater than 6 months require an explanation

Disclosure questions:

• All disclosure questions are answered. Adverse responses to the following questions must be explained in the application:
1. Reasons for inability to perform the essential functions of the position
2. Present illegal drug use
3. History of loss of license and felony convictions
4. History of loss or limitation of privileges or disciplinary activity

Malpractice Insurance:

• Current malpractice insurance coverage information or a copy of the insurance fact sheet, even if the amount of coverage is $0. If a practitioner is not required to carry malpractice insurance, they must provide evidence of such.
  • The fact sheet must indicate the insured entity is either the provider or the provider's practice location

If a practitioner’s application is missing any of these four elements, we may conduct outreach to make the practitioner aware that they need to update their application. If we exhaust outreach and the practitioner does not update their application to meet compliance, we will not move forward with credentialing. We will then make the health plan or organization aware that the practitioner did not have a compliant application.

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