Essential Data for a Credentialing Tracking Worksheet

Healthcare credentialers must collect an average of 30 documents per provider to initiate and complete the credentialing process – also known as primary source verification (PSV). Compiling that volume of information for all of your organization’s providers is hard enough. Keeping track of what you do and don’t have may seem impossible without help. That’s where a credentialing tracking worksheet is invaluable.

What Is Credentialing?

Provider credentialing involves verifying a person’s education, training, licensure, certifications, and work experience, among other things. Traditionally, credentialers call the appropriate entities to verify transcripts, licenses, etc. They also conduct background checks, which require calling law enforcement and other regulatory agencies for criminal records and malpractice history.

After gathering and verifying all information, approved medical professionals submit information to enroll with payers and apply for privileges if needed. The credentialing process is then reviewed and renewed every two to three years (known as recredentialing).

Challenges To Collecting Credentialing Information

The volume of the documents each provider must have to be credentialed is only one of the reasons that a credentialing tracking worksheet may be needed. Many other challenges in the process require organization, persistence, and documentation.

1. Multiple Data Sources: Information comes from state licensing boards, educational institutions, previous employers, and professional organizations. Tracking what you’ve collected and what is still outstanding is time-consuming and prone to errors.
2. Regulatory Requirements: Healthcare credentialing must comply with numerous regulatory requirements and standards, which can vary by state and specialty. Ensuring you’ve collected everything adds a layer of complexity.
3. Data Accuracy and Verification: Verifying the accuracy of the information is crucial but challenging. Inaccurate or outdated information can lead to compliance issues and potentially compromise patient safety.
4. Frequent Updates: Credentialing data must be regularly updated as licenses and certifications expire, new qualifications are obtained, and regulations change. Keeping the spreadsheet current requires continuous effort.
5. Communication Barriers: Obtaining information from healthcare professionals can be difficult due to their busy schedules. Delays in communication can slow down the data collection process.
6. Lack of Standardization: The documents you’ve collected are likely in different formats and standards, so having one place where everything is tracked is handy.

Collecting and assembling thorough provider credentialing information cannot be overstated. However, due to its critical nature, credentialing often takes a long time. Following up with each primary source can take weeks; additional investigation is frequently required for conflicting or missing information. This is where checklists and credentialing management software make a difference.

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Comprehensive Credentialing Tracking Worksheet

Here’s what to include in a comprehensive credentialing worksheet.

Essential Information

• Provider Name
• Clinical and Hospital Staff Privileges
• Primary Source Verification
  • Driver’s License or U.S. Passport
  • Educational Degree
  • Practitioner degree (MD, DO, DPM), post-graduate education or training
  • Completion of a residency program in the designated specialty
  • National Provider Identification (NPI) number
  • National Practitioner Data Bank (NPDB) ID
  • Current license or certification in the state(s) in which the care provider will be practicing (no temporary licenses)
  • Certificate or acceptable substitute (if required)
  • Medicare/Medicaid participation eligibility or certification (if applicable)
  • Specialty (surgeons need board certification, RNs don’t need anything else)
• Exclusions
  • OIG-LEIE
  • SAM
• Work History
  • Five-year work history. If there are any gaps longer than six months, please explain
  • Statement of work limitations, license history, and sanctions (only required if you are applying to join UnitedHealthcare’s Medicare and Medicaid plans)
  • W-9 form

Helpful Information

• Primary Location
• Department
• Position
• American Medical Association (AMA) ID
• Council for Affordable Quality Healthcare (CAQH ProView) ID
• Medicare Eligibility
• Vaccines
• Medical Malpractice Insurance

Next Steps

• Identify insurance companies/payers of interest
• Review all documents and ensure everything needed is assembled and accurate
• Create or update the provider’s CAQH profile
• Gather enrollment applications
• Fill out applications
• Send to provider for signatures
• Submit applications to insurance entities
• Confirm receipt
  • Follow Up — Either payer’s cited turn times or 30 days, whichever is shorter
    • Continue follow-up until receiving approval or denial
    • Submit appeal if denied
• Complete contract negotiations
• Review and sign the payer agreement
• Begin in-network services 

Complete Insurance Credentialing Faster and Accurately

Insurance credentialing can be a long, difficult process. As you’ve likely realized, even a great credentialing tracking worksheet is still a lot of work! It’s why many healthcare organizations are adopting credentialing software to streamline data collection, automate processes like license verification and exclusions monitoring, and follow a proven enrollment workflow. See how you can improve your process with MedTrainer Credentialing. Watch a 3-minute video.