Running a provider group requires managing many moving parts for practice owners, particularly those who are just starting out. For clinicians, learning all of the various credentialing and enrollment terms and definitions can be arduous. And that’s on top of all the decisions clinicians starting a new practice need to make.
For example, you’ll need to determine whether to go paperless and use software, which onboarding policies and procedures to implement, as well as how to manage enrollment applications (including following up with payers). If you choose to streamline your provider network management and billing processes, you’ll need to develop a good understanding of credentialing and enrollment terms and definitions.
This article provides a nice introduction and overview of common credentialing and enrollment terms and definitions that healthcare teams and payer organizations use. We’ve also included a free, downloadable glossary, providing credentialing and enrollment terminology 101, that you can use as a quick-reference guide when credentialing providers or enrolling with payers.
The glossary highlights basic terms and definitions you need to know as a provider operations team member. You can also include this guide as a handy PDF in providers' onboarding packets.
1. Important timelines
Understanding key timelines for credentialing and enrollment is essential for maintaining compliance and ensuring smooth operations in your healthcare practice. Here are some industry averages:
Initial credentialing
Typically takes 60-90 days—from application submission to approval, this period involves primary source verification, background checks, and committee reviews.
Re-credentialing
Occurs every 2-3 years—providers must update and verify their credentials periodically to maintain compliance and ensure quality care.
Initial provider enrollment
30-90 days—the time from submitting enrollment forms to receiving approval from insurance companies, allowing providers to start billing for services.
Revalidation
Every 3-5 years—payer organizations or health plans require periodic revalidation to ensure that provider information remains accurate and up-to-date for ongoing billing privileges.
2. Credentialing terms and definitions
Credentialing
Also known as “healthcare credentialing” or “doctor credentialing”, credentialing is the process of verifying, with a primary source, that the provider has the qualifications they claim to have, that they are who they say they are and that they have the right “credentials” (e.g. education, state licenses, training, etc) to perform a certain healthcare service. This is often referred to as “direct credentialing.” Once an enrollment application is sent to a payer, the payer will initiate credentialing of that provider.
Credentialing automation
Streamlines provider onboarding, verifications, and committee-ready credential file creation and committee management through an automated credentialing platform, saving time and reducing errors.
Credentialing committee
A group reviewing and approving providers’ credentials to ensure compliance and quality standards.
CVO credentialing
A Credentialing Verification Organization (CVO) handles verification tasks, ensuring providers meet required standards.
Credentialing software
The best credentialing software is a digital tool managing the entire credentialing process, making it faster and more accurate.
Primary source verification/primary source verifications
Directly verifying a provider's qualifications from the original source to ensure authenticity.
Provider onboarding
Also known as clinician onboarding or physician onboarding process is the process of integrating new clinicians into an organization, ensuring they meet all requirements.
NCQA credentialing standards 2024
Guidelines set by the National Committee for Quality Assurance to ensure consistent and quality credentialing practices.
Delegated agreement
A provider group may have this agreement with payers that gives them the authority to conduct their own credentialing.
Delegated agreement support
Assistance with setting up and maintaining agreements where credentialing duties are delegated to a healthcare organization.
Delegated entity
An organization authorized to manage credentialing on behalf of providers, ensuring compliance with payer standards.
Delegated credentialing
If a delegated agreement is in place, a provider group outsources credentialing to vendors who perform delegated credentialing on their behalf. The organization may also do this in-house if they are NCQA accredited (and it’s completed under those guidelines.)
CAQH credentialing
CAQH is a central online repository of provider data. CAQH credentialing is a streamlined process where providers submit their credentials through the CAQH ProView platform, ensuring they meet payer requirements while managing legal compliance in the healthcare industry. This central repository simplifies data sharing with multiple insurance companies.
CAQH integration
enables admins or providers to import provider profile information directly from CAQH to speed up and streamline their Medallion profile completion.
Re-credentialing
The periodic process of updating and verifying a healthcare provider's credentials to maintain compliance and ensure ongoing quality care. This involves reviewing licenses, certifications, and professional history to meet regulatory and payer requirements.
3. Enrollment terminology 101
Payer enrollment
The process of registering a healthcare provider with insurance companies, enabling them to bill and receive payment for services rendered.
Provider enrollment
The process of registering a provider with insurance companies to bill for services.
Group enrollment
Registering a group of providers with payers, simplifying the enrollment process.
Payer enrollment services
Assistance with enrolling providers or groups with insurance companies to streamline billing and reimbursements.
Roster management
Maintaining an updated list of providers affiliated with a healthcare organization.
Ongoing monitoring
Regularly checking providers' credentials to ensure continuous compliance with standards.
4. Common questions
What’s the difference between credentialing and privileging?
Credentialing vs privileging: Credentialing verifies qualifications; privileging grants permission to perform specific procedures at a facility.
What does it mean to be a delegated vs. non delegated provider healthcare professional?
A delegated provider: whose credentialing is managed by their organization, making the process faster and more efficient. A non-delegated provider handles their own credentialing directly with insurance companies, often more time-consuming and complex.
How Medallion streamlines credentialing and enrollment for provider groups
Medallion is SOC 2-compliant provider network management software with everything you need to unite provider operations and empowers end-to-end automation workflows for credentialing, enrollment, and monitoring—all built into the platform.
If you’ve been considering switching to modern software, Medallion removes burdensome administration tasks, enabling healthcare organizations to quickly and accurately manage and grow their provider networks with our AI-powered automation technology—so you free your healthcare team to focus on what matters.
See Medallion by booking an introductory call today.