Provider Credentialing
Provider credentialing is the formal process of verifying a healthcare provider's qualifications, licensure, training, board certification, and practice history to authorize specific clinical services within a health system or to bill a specific payer.
What is Provider Credentialing?
Credentialing operates in two parallel tracks. Hospital credentialing and privileging — governed by The Joint Commission standard MS.06.01.01 — requires hospitals to verify credentials and formally grant clinical privileges to all practitioners before they provide care. Payer credentialing is a separate process through which providers enroll with each individual payer to establish the right to submit claims and receive reimbursement. The credentialing process encompasses application submission, primary source verification (confirming medical school graduation, residency completion, state license status, DEA registration, and a query to the National Practitioner Data Bank — NPDB), peer references, and committee review. Hospital credentialing typically takes 90–180 days; payer credentialing with individual commercial payers typically takes 90–120 days per payer. CAQH ProView is the industry's centralized credentialing data repository, used by 85%+ of health plans, enabling providers to complete their credential data once and grant payers access rather than submitting duplicate applications. The revenue impact of credentialing delays is direct and quantifiable: a provider cannot bill during the credentialing gap, costing $500–$2,000 per day for primary care and $2,000–$10,000 per day for high-volume surgical specialties.
Why It Matters for Healthcare Analytics
For new provider onboarding, each day of credentialing delay represents real lost revenue. Tracking the credentialing status of every provider across every payer — with aging on pending applications and alerts for expiring licenses, DEA certificates, and board certifications — prevents unintentional lapses that create claim denials and compliance risk.
How Vizier Tracks Credentialing
Upload your provider roster and credentialing status data, then ask "Which providers have payer enrollment pending for more than 90 days and what is the daily revenue at risk?" — Vizier tracks credentialing status by provider and payer, flags expirations, and quantifies the revenue impact of outstanding enrollment gaps.