PHYSICIAN CREDENTIALING FAQ’s

Physician Credentialing (FAQ’s):

Why do I need to complete a reappointment application EVERY two years if most of the information has not changed?

In compliance with state law, accreditation bodies and Quality Assurance, it is necessary to evaluate each medical staff member’s performance, activity, licensure, clinical competence (including but not limited to sanctions) AT LEAST every two years.

Why do I need to complete a re-appointment application 6 months before my current appointment expires?

Our current re-appointment processing time averages 4 months from receipt of application to final approval. To ensure applications are processed within the time frame of the providers’ current appointment, it is essential to mail packets 180 days in advance and to receive them back within 30 days.

How long does it take to process a new appointment application?

Our goal is to complete new appointment applications within 90 days. However, this time frame is contingent upon the receipt of all verifying documentation.

Who should I contact if I have a question on or would like to change my current clinical privileges?

If you would like to change or review your current clinical privileges, contact your Lloyds Credentialing Coordinator directly. The Credentials Coordinator can assist you in completing the appropriate clinical privilege forms.

How long will it take to process my application?

Most applications are processed within 6 to 8 weeks. The more complete the application, the easier it is to identify what primary source verifications are needed. However, the length of time necessary to obtain hospital privileges can be very difficult to determine. There are several factors that affect the time required to process a credentialing application, such as, Foreign verses American Medical Graduate, appropriate peer references, professional liability history, number of years out of training, training or practice outside the United States, practice as a locum tenens physician, employment history, etc. Please note, the time frame indicated above is a generalization. Your privileging process could take much less time, but unfortunately, in extreme cases, it could take much longer based upon your professional history.

Why does the credentialing process take so long?

The bylaws and JCAHO require primary source verification of all your activities since medical school. We are dependent upon responses to our queries regarding training, experience, affiliation, professional reference, licensure, and any malpractice information, etc. It is imperative your application be filled out in detail regarding dates (month and year), addresses, and contact information.

Of what does the credentialing process consist? What is primary source verification and why is it necessary?

The credentialing process consists of activities designed to collect relevant information that will serve as the basis for decisions made regarding appointments and reappointments to hospitals. When an applicant is being evaluated, hospitals are required to verify the information in the application that relates to the individual’s licensure, training, experience, and competence from primary sources. Your application is then evaluated by comparing the information provided on your application with the information provided by the primary source. Additional information may be required to fully evaluate each applicant. “Primary source” is the original source of a specific credential that can verify the accuracy of a qualification reported by an applicant. Examples include medical school, graduate medical education program, and state medical board. The credentialing process and primary source verification are required by federal, state and other regulatory agencies to ensure patient safety.

How can I help to expedite the credentialing process?

Fill out your application as completely and accurately as possible. If you supply incorrect or incomplete information, hospital credentialing staff must spend valuable time searching for correct addresses and/or phone/fax numbers, which could cause unnecessary delays with hospital credentialing. Please remember, the responsibility for providing accurate credentialing information lies with you, the applicant. Make certain that the professional references provided have current (within the last 24 months) personal knowledge of your current clinical competence, ethical character, health status and ability to work cooperatively with others. One of your three references must be in your specialty.

Provide a complete and accurate listing of current and previous affiliations and training programs, and a complete history of your professional liability coverage for the past 10 years (if applicable). Any gaps in your coverage history must be explained. You must provide explanations of any gaps in time. A time gap ofless than three months’ duration must be explained in writing by you; for time gaps of three months or greater, a contact must be provided for verification.

Return your complete application in a timely manner and allow sufficient time for processing. Do not wait until you have obtained a license. Hospital credentialing and the licensure process can work in unison. The credentialing process does not begin until your completed application has been received by the Lloyds Credentialing Services Department. A photo and all required documents must be provided.

Where can I apply for my DEA certificate?

See the DEA’s online application system.

What is the objective of the CAQH Physician Credentialing Data Initiative?

The CAQH Universal Provider DataSource is designed to accomplish administrative simplification by gathering credentialing data in a single repository that may be accessed by participating health plans and other healthcare organizations. Its objective is to simplify the credentialing data gathering process and enable physicians and other health care providers to easily update their information.

Why is the CAQH Universal Provider DataSource important to me?

Healthcare organizations, health plans and hospitals evaluate physicians and other health care providers with whom they contract services to assure that the healthcare providers under contract are adequately trained, certified and/or licensed to provide care. Credentialing involves a tremendous amount of paperwork and administrative time. The CAQH Universal Provider DataSource reduces that.

How often must my information be updated?

You will be sent automatic reminders to review and attest to the accuracy of your data. You must review and authorize data once every four months. This is easily accomplished through a quick online visit or by calling the CAQH Helpdesk at 888-599-1771. You can make changes to your record anytime by requesting a change form by phone or by directly accessing your information online.

Why do I need to review and attest to my information three times a year?

Because many health plans with which you do business will be using this system for re-credentialing and ongoing updating of provider directory records, it is important that the database contains the most accurate and up-to-date information possible. By checking and attesting to your data three times a year, participating health plans can access current information from the database at the time of re-credentialing or database updates, without having to contact you repeatedly. This will help to ensure that you continue to conform to the requirements of each participating health plan.

Can I use the CAQH database to report any changes to my practice such as address, phone numbers, and new associates?

The notice section of your agreement with each of the participating health plans typically requires you to communicate certain changes to your personal information immediately. Rather than contact each of these plans individually, you can enter your changes once into the CAQH database for all authorized participating plans to access. Please be aware, however, that only plans that participate in the CAQH Universal Provider DataSource, and that have been authorized by you to access your information, will receive any changes. You will still need to contact any non-participating plans directly.

Can any health plan access my data?

No. You control which plans have access to your application information. When completing the application, you will indicate which participating health plans and healthcare organizations will be authorized to access your application data.

What if I participate in a health plan that is not participating in the CAQH Universal Provider DataSource?

f you are contracted with a health plan that is not participating in the CAQH Universal Provider DataSource, you will need to continue to deal with that organization directly, separate from the database process. Healthcare organizations and health plans are invited to participate in the CAQH Universal Provider DataSource, regardless of whether they are members of CAQH. If one of the health plans with which you work is not currently participating in the initiative, please ask them to visit the CAQH Website at www.CAQH.org or call (202) 861-1492 .

Do I need to complete the entire application?

Yes, you are expected to complete all questions on the application. The electronic application will present the questions to you in an interview style approach, with logic that presents the questions that are relevant to your particular specialty or provider type. The system is designed to allow you to complete the application over time. You can stop any time, save what you have completed and return later to finish the process. The entire application must be completed prior to your verification of its accuracy, and before the participating health plans that you have authorized can access it.

Why does the CAQH application ask for such practice specific details?

CAQH is collecting additional information about your practice so that participating health plans can improve and maintain the data in their provider directories and provider data systems, as well as to have the full scope of information needed to conduct initial credentialing and re-credentialing. Health plans often collect practice information on the credentialing application so health plan members can make more informed selections of providers. It also potentially reduces the volume of calls to your office for this practice-specific information. As with all of the other questions in the application, it is important that you complete the sections on your practice, and attest to the accuracy of your responses.

My health plan operates in a state with a mandated credentialing application form and/or process. Will we be required to use the CAQH application and database?

In states where legislation has passed mandating the use of a standard credentialing application form, the data collected through the CAQH credentialing database and data collection process will include the data elements and/or form as is required by the state. The system will automatically ask the provider the necessary questions to fulfil the requirements for the state in which the provider’s primary office address is located.

Will Primary Source Verification be included as part of the CAQH Credentialing Initiative?

Currently, the CAQH Credentialing Initiative addresses only the data collection part of the credentialing process. Under this phase of the CAQH initiative, participating health plans and other related organizations will independently perform primary source verification on certain data that is collected, as well as make their own decisions about whether a provider meets that organization’s standards for participation. CAQH may, as part of a later phase of activity, pursue relationships with credentialing verification organizations to streamline the primary source verification steps of the process for participating health plans.