Gateway to the provider network.
1 AI translation · Healthcare / Health Plans
You verify provider credentials for initial credentialing and recredentialing (typically every 3 years): medical education, residency/fellowship, board certification, state licensure (every state of practice), DEA registration, malpractice history (NPDB query), malpractice insurance, hospital privileges, work history, sanctions screening (OIG, SAM, state exclusion lists), and professional references. NCQA credentialing standards (for health plan accreditation) specify the verification requirements. Volume can be enormous: a large health plan credentials thousands of providers. Delegated credentialing (delegating to an IPA or medical group) adds another layer of oversight.