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Medical Credentialing

What is doctor credentialing? Credentialing is a process used to evaluate the qualifications and practice history of a doctor.

This process includes a review of a doctor’s completed education, training, residency and licenses. It also includes any certifications issued by a board in the doctor’s area of specialty.

The Insurance companies credentialing process evaluates the qualifications of doctors who provide care to Insurance companies members. Insurance company conducts this process before the doctor is permitted to join the Insurance company network.

Insurance company also reviews doctors’ credentials on a regular basis, following standards established by states, regulatory bodies and accrediting organizations.

Major accrediting organizations include the National Committee for Quality Assurance  (NCQA) and the Joint Commission. These independent, nonprofit organizations set quality standards for health care companies, credentialing organizations and hospitals.

The credentialing process does not guarantee that members will receive any level of quality or service from participating doctors. Participants are independent doctors in private practice. They are not agents or employees of Aetna.

Why is doctor credentialing important to Insurance companies members?

Credentialing plays an important part in assuring members’ access to quality health care.

The process is mature and efficient. For this reason, we are able to give members access to doctors quickly after they sign contracts with Aetna.

Insurance companies confirm credentials for ALL medical types of health-care practitioners. This includes psychotherapists, chiropractors, podiatrists, physical therapists and nurse practitioners, among others.

What does the Insurance company doctor credentialing process involve?

Credentialing at Insurance companies includes (but is not limited to) the following:

  • Gathering information about a doctor’s background and qualifications through a formal application process
  • Checking the background information for completeness and accuracy:
  1. Checking the information against reliable sources, including the National

Practitioner Data Bank and the American Board of Medical Specialties

  1. Contacting:
  • Any state where the doctor has a medical license, to be sure there are no limitations on practicing medicine in that state
  • Schools and hospital programs, to be sure the doctor’s training is complete and

accepted by the specialty board

  • The National Technical Information Service, Drug Enforcement Agency or Controlled Drug Substance Registration, to confirm that the doctor is authorized to write prescriptions
  • Medicare/Medicaid, to make sure that the doctor is not banned from caring for

Medicare/Medicaid patients

  1. Reviewing the doctor’s:
  • Personal conduct history, to determine if any disciplinary actions have been taken
  • Malpractice insurance, to confirm active coverage
  • Malpractice claims history
  • Hospital privileges history, to determine if privileges have been lost or limited
  • Work history and employment background
  1. Reviewing the doctor’s information with an Credentialing and Performance

Committee to determine whether or not the doctor should be included in our network

Some of the specific information gathered includes:

Provider Name: This information is self-reported at least every three years or more often according to state or federal requirements on the application and is accepted through a signed document from the doctor that states the information is accurate and correct.

Provider Gender: This information (male, female) is self-reported at least every three years or more often according to state or federal requirements on the application and is accepted through a signed document from the doctor that the information is accurate and correct.

Specialty (ies): This is the doctor’s special field of practice or expertise. If the provider has contracted with Insurance companies to provide services in more than one specialty, all will be listed. This information is self-reported at least every three years or more often according to state or federal requirements on the application.  Insurance company checks the practitioner’s highest level of training in his/her specialty and checks board certification status through primary source verification.  This is the process of confirming with the certifying board and/or facility where the doctor completed residency training.

Patient Age Focus: When available, DocFind will display information about whether the provider has a patient age specialization.

Languages Spoken: This information includes the languages that the practitioner speaks and is self-reported at least every three years or more often according to state or federal requirements on the application and is accepted through a signed document from the doctor that states the information is accurate and correct.

Hospital Affiliation: This is a listing of the hospitals where the provider has privileges.

If you require hospital care, you may be directed to one of the hospitals listed.  This information is self-reported on the application. The practitioner’s hospital affiliations are checked by contacting hospitals to verify the information at least every three years or more often according to state or federal requirements.

Medical Group Affiliation: This is a listing of the group practice that the practitioner is part of when applicable. This information is self-reported at least every three years or more often according to state or federal requirements on the application and is accepted through a signed document from the doctor that states the information is accurate and correct.

Board Certification: When a physician is board certified, it means that he or she has applied for and been awarded certification from the American Board of Medical Specialties, American Osteopathic Association, or other Insurance companies recognized boards depending on the specialty.  To become board certified, a physician must:

  • Graduate from an accredited professional school
  • Complete a specific type and length of training in a specialty
  • Practice for a specified amount of time in that specialty
  • Pass an examination given by the professional specialty board

Board certification is a voluntary process. Most certifying boards now require physicians to be recertified at specified intervals. The specialty board certification of the practitioner is self-reported on the application and is checked before contracting and at least every three years or more often according to state or federal requirements through one of the following primary sources:

  • American Medical Association
  • American Board of Medical Specialties. To access this site go to: www.ABMS.org.

On this site, in the Consumer section, you will find information about board certification, how to verify that your doctor is board certified and some general tips on becoming a more educated consumer of health care.

  • American Osteopathic Association Physician Profile Report
  • American Board of Podiatric Surgery
  • American Board of Podiatric Orthopedics and Primary Podiatric Medicine
  • American Board of Lower Extremity Surgery, if applicable Specialty Dental Boards: Dental Specialty Boards Recognized by the American Dental Association Counsel on Dental Education and Licensure (CDEL)

Office Status: This indicates whether or not a provider is accepting new patients. It is recommended that you call the provider’s office to confirm.  This information is self- reported on the application at least every three years or more often according to state or federal requirements and is accepted through a signed document from the doctor that states the information is accurate and correct. Practitioners may also notify Insurance companies between credentialing cycles of updates and DocFind is updated with new information every week.

What are the results of commitment to credentialing?

  • Insurance companies has a centralized credentialing verification unit that is NCQA (National Commission for Quality Assurance) certified for 10 out of 10 certification options and URAC CVO accredited.
  • Insurance companies perform credentialing on 144,000 doctors annually.
  • Insurance companies maintain a Customer Service unit to meet the specific needs of the doctors.
  • Insurance companies have a mature and efficient process that is used consistently for doctors in all our health plans.