Complete Guide to CAQH Credentialing Application

Did you know that the Council for Affordable Quality Healthcare (CAQH) has more than 4.8 million provider records in its database? Besides, 80% of physicians in the US trust the portal for efficient sharing of data with different health plans.

But how can you create a profile on it, and what benefits does it offer to providers and payers? This comprehensive guide answers these questions and everything else you need to know about successful CAQH credentialing. So, continue reading!

What is CAQH Credentialing?

CAQH credentialing enables healthcare providers to submit and update all their professional information. That is, it acts as a central hub by streamlining the verification process for health plans, networks, and organizations.

CAQH Number

It is a unique identifier assigned to a healthcare provider when they first register with the system.

Purpose

It acts as a digital credentialing ID for access to your qualifications and professional certifications.

Usage

When you provide the CAQH number to insurance payers, it becomes easier for them to locate and download specific data during the credentialing, enrollment, and contracting processes.

CAQH ProView Profile

It can be defined as a centralized, secure online database. Healthcare providers enter and maintain their practice and professional details to get credentialed with government and commercial insurance payers. 

Simply put, it is a tool for streamlining administrative tasks, as it allows providers to submit a single, standardized profile to multiple payers. This eliminates the need for redundant paperwork and directory services.

Your CAQH profile can contain the following:

• Disclosure questions (legal/disciplinary history).
• Education, training, and board certifications.
• Personal and contact information.
• Professional liability (malpractice) insurance coverage.
• State licenses and DEA registrations.
• Work history and practice location details.

CAQH Attestation & Re-Attestation

Before we discuss the benefits of the CAQH profile, let’s first understand what attestation means. It is the legal electronic signature you provide to confirm that all provided information is accurate and current.

Here’s how attestation and re-attestation differ:

Initial Attestation	Re-Attestation
When you first complete your profile on the CAQH ProView, you affirm that all information is accurate and release the data to insurance payers for credentialing.	CAQH requires you to log in and re-verify your information every 120 days to keep your data active.

Why Does Re-Attestation Matter?

It is an integral process to keep your profile active on CAQH ProView. In case you fail to re-attest, you may experience the following issues:

• Inactive CAQH profile.
• Insurance companies will lose access to your data.
• Contracts with payers may be terminated.
• Payment delays.

Benefits of CAQH Credentialing for Payers

When we see the CAQH from the payer’s perspective, it offers the following benefits:

Administrative Efficiency

With the CAQH ProView database, insurance companies eliminate the need to maintain large-scale paper-based intake systems. This not only fast-tracks the credentialing process but also reduces the costs associated with manual data entry, mailing application packets, and physical document storage.

Standardized Data Collection

CAQH credentialing enables data standardization, as each healthcare provider submits their professional credentials in the same format. But, how does it help? 

This uniformity allows insurance companies to automate the primary source verification (PSV) process. Moreover, it helps payers input the provider data into their internal directories and claim systems without delay.

Seamless Network Enrollment

Since all the data is digital in a CAQH profile, manual errors are significantly reduced, and data processing becomes faster. As a result, the credentialing process moves quickly, allowing payers to expand their network with faster provider enrollments. 

This really matters because the provider network of any payer is its backbone, ensuring the members have better access to care.

Access to Clean Provider Directories

Did you know that, on Nov 3, 2015, the California Department of Managed Health Care (DMHC) fined two of the state’s largest health plans for inaccurate provider directories? It fined Anthem Blue Cross $250,000 and Blue Shield of California $350,000.

This all changes with CAQH ProView. It requires healthcare providers to re-attest every 120 days so insurance companies have access to up-to-date and accurate information. 

Moreover, it allows payers to comply with federal and state regulations and avoid the risk of fines for outdated contact or practice information.

As per a report by Medical Marketing and Media (MM+M), most states have not fined a single insurance company for publishing directory errors since 2019.

Faster Re-Credentialing

Most payers re-credential healthcare providers every 2-3 years. This maintenance becomes seamless since insurance payers can simply pull the updated digital file using the CAQH number rather than requiring the provider to fill out a brand-new application from scratch.

Risk Mitigation

CAQH ProView provides complete provider information from professional history to disciplinary actions (if any) in a chronological format. This enables clinical committees to make informed decisions during the peer review process.

Benefits of CAQH Credentialing for Healthcare Providers

Not sure how a ProView Profile can help you get credentialed with insurance payers? This section will address your uncertainties in detail:

Leverages a Unified Professional Profile

With a CAQH profile, you do not have to manage multiple applications for every insurance carrier. You can store all information in one place.

Here’s how it helps:

• Single Repository: You can keep your board certificates, licenses, and malpractice insurance in a single digital folder.
• Easy Access: You can download your own data to apply for new state licenses or hospital privileges.

Eliminates Administrative Redundancy

It also eliminates the need to perform repetitive tasks of filling out the same educational, professional, and demographic data multiple times.

Here’s how it helps:

• Automated Updates: Whenever you renew a license, upload it to your CAQH profile. It will automatically notify all authorized payers.
• ‘Apply Once’ Logic: You only need to enter your educational data and work history one time and release it to as many insurance carriers as you want.

Fast Tracks Insurance Enrollment

Having an attested, complete, and updated profile on CAQH ProView speeds up the insurance enrollment. How? By accelerating the following processes.

Here’s how it helps:

• Faster Credentialing: It lets payers pull your data immediately, rather than waiting for you to mail them the paper packet.
• Quicker Contracting: Your CAQH profile data helps accelerate the data verification phase so that you may start seeing patients.

Reduces Operational Overhead

CAQH ProView helps healthcare practices minimize the administrative overhead associated with manual credentialing.

Here’s how the CAQH profile helps:

• Lower Cost and Paperwork: Overhead cost is reduced significantly since there is no need to print, mail, or track the document packets.
• Reduced Staff Time: With no need to spend time on missing credentialing documents, your administrative staff can focus on patient and billing-related activities.

Improves Data Integrity & Security

The risk of human errors decreases significantly since you do not have to handle the credentialing data manually. That is, it enhances data accuracy and security.

Here’s how the CAQH ProView helps:

• Error Prevention: The portal highlights missing fields or expired documents before you can attest.
• Secure Sharing: It offers an access control feature. That is, you can manage which carriers can view your CAQH profile.

Ensures Industry Compliance

When you maintain an active CAQH profile, it becomes easier for you to stay compliant with industry standards.

Here’s how it helps:

• Standardized Format: The CAQH ProView format matches the expected format of most major health plans nationwide, ensuring professionalism.
• Re-Attestation Reminders: It also notifies you every 120 days to check your data, re-attest, and prevent accidental contract terminations.

Common CAQH Provider Credentialing Challenges

Listed below are some of the common CAQH credentialing challenges that healthcare providers experience:

• It requires providers to re-verify their data every 120 days. Thus, if you fail to re-attest, it will result in an ‘inactive’ CAQH Proview profile status, leading to claim denials.
• If your work history has any gaps exceeding 30-60 days, you must explain the reason in writing. This increases administrative burden for long-tenured healthcare providers.
• Even with a 100% complete profile, authorization oversight can happen, preventing payers from accessing your account. Why? Because on the ProView portal, you must manually grant access to specific insurance payers.
• When you upload a new license image but forget to update the corresponding expiration date in the data field, it can flag it as ‘data mismatch’.
• Managing multi-location provider profiles is complex since it requires you to manage unique tax IDs, NPIs, etc., and is prone to data entry errors.
• You may experience technical upload issues while creating a CAQH profile. That is, the portal has file format and size limitations.
• Discrepancies between CAQH data and state board records can stop the enrollment process entirely until they are manually corrected. For example, a healthcare provider updates her ProView profile with her married name, Sarah Miller-Smith. However, her state medical board license is still listed under her maiden name, Sarah Jane Miller.

CAQH Credentialing Application Process

We have divided the CAQH ProView application process into five phases for simplicity and better understanding:

Phase # 1: Registration and ID Assignment

This phase involves the following steps:

• Before starting CAQH registration, you must have a Type 1 NPI.
• You can either self-register at the CAQH ProView portal or may receive an invitation from the payer (e.g., BCBS, Aetna, etc.).
• Once registration is complete, you will be assigned a CAQH number.

Phase # 2: Data Entry (ProView Profile Completion)

Now that you have successfully created an account with CAQH, it is time to start entering the necessary information to complete your ProView profile. The following table offers a glimpse into the several sections of the CAQH credentialing application:

CAQH Application Sections	What Is Required?
Personal Information	Legal name, aliases, and demographics.
Professional ID Numbers	SSN, NPI, DEA, and state license numbers.
Education & Training	Medical school, residency, and fellowship details (including start/end dates).
Work History	A chronological, month-by-month list of all professional activities since graduation.
Malpractice Insurance	Policy numbers, coverage limits, and carrier details.

Phase # 3: Document Uploads

You must upload digital copies of supporting documents to complete your CAQH profile, including the following:

• Board certifications.
• DEA and state-controlled substance certificates.
• Malpractice insurance face sheet.
• State medical license.
• W-9 form for the practice tax ID.

Phase # 4: Attestation and Authorization

This phase involves the following:

• The CAQH system will run an automated check and flag missing fields or unexplained gaps for correction.
• Once all fields are complete, you must electronically sign (attest) that the information is accurate.
• Then you can choose which health plans are allowed to access your data.

Phase # 5: Post Application Maintenance

Your CAQH credentialing application requires regular maintenance to ensure data accuracy. Here’s what it involves:

• After every 120 days, you must log in again, confirm the data is still correct, and re-attest.
• As soon as a license or insurance policy expires, upload the updated document to prevent a lapse in credentialing.

Partner with NeuraBill to Streamline Insurance Credentialing

Are you overwhelmed by all the details we shared regarding CAQH credentialing? It is understandable since, as a healthcare provider, your hands might already be full with clinical duties. 

So, what can you do to offload time-consuming administrative activities, like creating and managing a ProView profile, from your shoulders? You can outsource medical credentialing services to NeuraBill, since it includes CAQH account review and maintenance as well.

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