While medical credentialing might be considered a modern concept, credentialing dates as far back as the practice of medicine itself. The first documentation of medical credentialing can be traced to 1000 BC by the ancient Persian, Zoroaster, in which physician licensure was outlined in The Vendidad, the book of the law.
The Vendidad stated that in order to earn the right to practice medicine a candidate had to prove himself by successfully treating three heretics. If all three lived he was considered fit to practice medicine. If all three died, the candidate was denied the right to practice for the entirety of his lifetime. While the modern process of physician credentialing has changed substantially since then, the weight and importance of it have not.
What Is Medical Credentialing Today?
Modern medical credentialing requires more comprehensive provider data and exclusion screening rather than the treatment of “test” patients. Today, medical credentialing requires the thorough review of a practitioner’s professional medical data including their:
- Education
- Training
- Residency
- Licensing
- Certificates
- Qualifications
- Work History
Medical credentialing carefully reviews a healthcare provider’s qualifications to practice. Credentialing must be completed before hiring and should be consistently monitored to stay compliant with industry regulations.
To keep a medical provider’s credentials current, medical credentialing must be completed multiple times throughout a provider’s career and must meet all the requirements established by the National Committee for Quality Assurance (NCQA) and The Joint Commission (TJC). Although medical credentialing can be labor-intensive, time-consuming, tedious, and costly for some organizations to handle on their own, it’s a legal requirement. For organizations with overburdened medical staff and limited resources, it’s helpful to have a Credentials Verification Organization (CVO) like Verisys to handle the task of credentialing your staff.
How the Provider Credentialing Process Works
The provider credentialing process typically begins when a healthcare organization receives a new application from a medical professional seeking to join the practice or facility. The organization collects documentation and initiates a thorough evaluation of the applicant’s background, qualifications, and history.
This process is often broken down into the following steps:
- Application Submission – The provider submits their personal, educational, and professional information.
- Primary Source Verification (PSV) – The organization directly verifies information with the issuing institutions and boards (e.g., medical schools, licensing agencies).
- Review of Exclusions and Sanctions – The applicant is screened against databases like the Office of Inspector General (OIG) and the System for Award Management (SAM).
- Credentialing Committee Review – A designated committee reviews the findings and makes a recommendation based on internal standards and regulatory requirements.
- Approval and Privileging – Once approved, the provider is granted privileges specific to their qualifications and scope of practice.
While the process may differ slightly depending on the facility or state, each step ensures that only competent, compliant professionals are allowed to deliver patient care.
Criteria for Effective Medical Credentialing
Verifying your providers against the following 13 criteria will help you evaluate if they are qualified to provide healthcare services:
- Evidence of Identity
- Government-issued photo identification
- National Provider Identifier (NPI) number
- I-9 documentation listed as List A or List B or List C as defined on the form
- Visa or employment verification card
- Education and Training
- Proof of course completion and completion dates from a domestic or foreign medical school, internship, residency, fellowship enrollment, clinical degrees, and any other relevant experiences in MM/YY format.
- Explanation of any time gaps
- Fifth Pathway certification if applicable
- Educational Commission for Foreign Medical Graduates (ECFMG) validation
- Military Service
- DD 214 if recently discharged; a complete list of military experience, including military branch and enlistment dates, if currently enrolled.
- Professional Licensure
- Complete list and/or copies of all professional licensure. These must include issuing state, license type, license number, status, and issue and expiration dates.
- DEA Registration and State DPS and CDS Certifications
- Full list and/or copies of Drug Enforcement Administration (DEA), Department of Public Safety (DPS), and/or Controlled Dangerous Substances (CDS) certificates. These must include issuing state, status, registration number, and issue and expiration dates.
- Board Certification
- Full list of Board-specialty certifications held, including original, recertification, and expiration dates.
- Affiliation and Work History
- Chronological, comprehensive list of all facilities where the provider has worked or had clinical privileges (academic appointments, hospitals, practice groups, surgery centers, etc.). These must include start date, date on staff, employment or staff status, verification or good standing, and end date.
- Explanation of any time gaps
- Criminal Background Disclosure
- Federal, state, and county databases
- Sanctions Disclosure
- Federal and state
- Health Status
- Records of physical or mental illness that could affect work
- NPDB
- Healthcare-specific information on state/federal criminal convictions or civil judgments
- Malpractice history and hospital sanctions
- Malpractice Insurance
- Comprehensive list of insurance carriers. This includes coverage dates and types.
- List of open, pending settled, closed, and dismissed cases
- Current Certificate of Insurance (COI)
- Professional References
- Professional references describing the provider’s current competence
What Is Checked During a Credentialing Process?
Credentialing involves an extensive background check to ensure the provider is competent, qualified, and legally permitted to practice medicine. During this process, organizations typically verify:
- Educational Background – Verification of degrees, residencies, and fellowships
- Licensure – Current and historical licenses, including status and disciplinary actions
- Board Certification – Specialty board credentials and recertification status
- Work History – Employment timelines, gaps, and clinical privileges
- Legal and Disciplinary History – Sanctions, malpractice claims, and criminal background
- Insurance Coverage – Active malpractice insurance and any open or closed claims
- Professional References – Peer recommendations evaluating clinical competency
- Health Status – Confirmation that the provider is mentally and physically fit to practice
These checks are essential for compliance with standards from regulatory bodies like The Joint Commission (TJC) and NCQA and are critical for ensuring patient safety and organizational integrity.
When Do You Need Medical Credentialing?
When starting a new practice, being hired by a new organization, or changing states, medical practitioners must undergo the processes of medical credentialing and privileging including:
- Provider credentialing: verifying and assessing education, training, licensing, qualifications, etc. which requires checking multiple databases.
- Provider enrollment: requesting participation in a health insurance network
- Provider privileging: authorizing and granting a licensed or certified healthcare practitioner’s specific scope of services
Evolving Credentialing for Safer, Smarter Healthcare
As the healthcare landscape continues to evolve, so must the systems that support it. Medical credentialing is no longer just a periodic task—it’s a critical, ongoing process that safeguards patient care and protects organizational integrity. To truly ensure that only qualified, competent providers are granted clinical privileges, healthcare organizations must go beyond traditional verification steps.
That’s where integrated healthcare credentialing platforms like Verisys come in. With advanced license monitoring and continuous data verification, organizations can track real-time changes in provider status, reduce manual workloads, and proactively address potential compliance gaps. These tools are essential for implementing effective provider compliance solutions that meet regulatory demands while supporting efficient operations.
Whether you’re credentialing one physician or managing thousands, having a reliable partner with scalable technology like FACIS® makes all the difference. Verisys empowers you to streamline credentialing, improve compliance, and ensure your patients receive care from thoroughly vetted professionals—every time.
 |
Written by Verisys Verisys transforms provider data, workforce data, and relationship management. Healthcare, life science, and background screening organizations rely on our comprehensive solutions to discover their true potential. Visit verisys.com to learn how we turn problems into power.
|
