Healthcare organizations rely on the National Practitioner Data Bank (NPDB) to guide credentialing and privileging decisions. Credentialing verifies a provider’s qualifications, training, and track record, while privileging defines the exact services they can deliver at a facility. This system protects patients by ensuring only vetted professionals provide care. The NPDB acts as a trusted clearinghouse...
Medicare and Medicaid are two major government health insurance programs, but their credentialing processes differ significantly for providers. Medicare is a federal program for seniors and certain disabled individuals, managed uniformly by the Centers for Medicare & Medicaid Services (CMS). Medicaid is jointly funded by the federal and state governments, so each state runs its...
Blue Cross Blue Shield (BCBS) is one of the largest health insurance networks in the U.S., covering millions of patients across regional plans nationwide. If you want to treat BCBS patients and get reimbursed, credentialing is a must—it’s how BCBS verifies your qualifications before approving you for their network. Without credentialing, you can’t bill...
UnitedHealthcare (UHC) credentialing is the process by which UHC reviews your professional qualifications—like your licenses, education, and background—to make sure you meet their standards before you can join their provider network. Providers must complete credentialing before billing UHC for services. Without it, claims will be denied, and you can’t see UHC patients or get reimbursed....
Credentialing is a process where insurance companies like Aetna check your background to make sure you’re qualified to provide healthcare services. It’s like Aetna’s way of ensuring you have the right education, licenses, and experience to safely care for their members. Aetna requires credentialing before they accepts claims from providers. This step helps protect patients...
The Provider Enrollment, Chain, and Ownership System (PECOS) is Medicare’s official online platform designed to help healthcare providers, groups, and suppliers manage their Medicare enrollment smoothly. Instead of dealing with complicated paper forms, PECOS offers a digital way to apply, update, and maintain your Medicare enrollment information all in one place. Managed by the Centers...
Recredentialing is one of the most important — but often overlooked — parts of staying active with insurance networks. Even if a provider has been credentialed before, payers require regular rechecks to ensure they still meet all quality, licensure, and compliance standards. Whether you’re a solo provider, part of a group practice, or manage a...
Credentialing has always been one of the biggest roadblocks for healthcare organizations. Whether you run a growing mental health group, a primary care clinic, a specialty practice, or an MSO, you already know the problem — every new provider means more paperwork, more follow-ups with payers, and long waiting periods before they can start seeing...
CAQH ProView is an online system where healthcare providers keep all their professional information in one place. Think of it as your digital credentialing profile that insurance companies rely on. Instead of sending your licenses, education details, and work history to every payer separately, you upload everything once into CAQH ProView—and payers pull the information...
If you’re a mental health provider, whether you’re a therapist, counselor, psychologist, or social worker, credentialing is one of those tasks you can’t avoid. Insurance companies want to verify your education, license, training, and background before they let you join their network. And without being in-network, it’s harder to get steady patients, and even harder...