Provider credentialing seems a very tedious process as it involves dealing with numerous documentation and multiple data points. There are also possibilities of errors and omissions in submitting, organizing, and evaluating data sets. There are significant setbacks credentialers face during provider credentialing. However, CAQH has resolved the issue and made the credentialing process very easy and error-free. But the question arises: what is CAQH & how does it relate to provider credentialing? Well, every piece of information you’re looking for about CAQH will be discussed in this article.
What is CAQH credentialing for?
CAQH is termed the Council for Affordable Quality Healthcare, and it is a non-profit organization that aims to simplify and streamline healthcare-related processes. Due to the increased number of credentialing applications and demand for qualified healthcare professionals, managing the credentialing process has become daunting. This is where CAQH plays a significant role by providing different tools and platforms that enhance data accuracy and security. There are various platforms that it provides that help healthcare providers and payers obtain and verify information.
- CAQH Proview: It is a central platform where all healthcare professionals can submit their information, which can’t be changed by another person. Insurance companies and hospital organizations can check providers’ information on this platform. There is no need for separate applications for each organization where healthcare professionals apply.
- CAQH Core: This platform is used to apply rules for electronic data exchange between healthcare providers and payers. This enhances standards of interoperability.
- CAQH Enrollhub: This platform is concerned with payment transfers and their records. Online payment transfers among healthcare professionals, payers, and other professionals are made on this platform. To reduce fraudulent claims, all types of transactions are recorded.
Role of CAQH in Provider Credentialing
What is the purpose of CAQH credentialing? CAQH credentialing for? These are questions providers generally ask? CAQH is helpful in making provider credentialing efficient by providing healthcare providers, payers, and credentialers with access to data. The detailed step-by-step information is given below:
1. Centralized Data Repository
CAQH has provided many platforms where providers can make their profiles. They add their personal and professional information on their profile. This profile acts as a data source for different credentialers and payers. This decreases the effort of writing and submitting separate applications for all organizations. When providers apply for credentialing in different hospitals, they just need to give their CQH profile to them. They have access to CAQH ProView and can verify all information. The administrative burden gets reduced by this, and revenue can be saved.
2. Streamline Primary Source Verification (PSA)
Primary source verification refers to checking the legitimacy of documents from the issuing boards and organizations. Traditionally, license boards and educational institutions are contacted, and documents are verified. But CAQH has made this process simple. Providers can only submit verified data on this platform. All organizations are interlinked on this platform, streamlining PSA and reducing the time and resources spent on contacting concerned institutions. Credentialing boards can make decisions quickly and accurately.
3. Ensuring Compliance with Regulations
CAQH aligns with Health Insurance Portability and Accountability Act (HIPAA) rules and regulations, which stress safeguarding the provider’s data and information. CAQH only allows limited access to legitimate authorities to protect providers’ information from misuse. This instills confidence among providers and payers to use that system.
The National Committee for Quality Assurance (NCQA) is a credentialing authority that has set some standards for data management and storage. CAQH complies with all standards to avoid violation penalties. Therefore, healthcare organizations use this system for all types of credentialing processes.
4. Ongoing Credentialing
Provider credentialing is not a one-time process. Healthcare professionals are credentialed periodically to check their physical, mental, and educational status and whether they align with healthcare standards. For this, CAQH supports ongoing credentialing and sends reminders to providers to update their information every 120 days to comply with state policies. CAQH acts as a single package for multiple activities, and most of the credentialing bodies use CAQH platforms for a quick and effortless credentialing process.
How to Use CAQH for Credentialing?
If a healthcare professional is applying for a job in different hospitals, then he has to undergo the credentialing process first. The credentialing process is done to check whether a provider is able to give medical services or not. What is CAQH and how does it relate to provider credentialing? For credentialing, the provider must have his data recorded on CAQH platforms so that credentialers can assess that data. There are following steps to record and maintain data on CAQH:
1. Register on CAQH Proview
Providers need to visit the CAQH Proview website and click on the sign-in option. Personal and professional information is necessary to sign in. It starts with basic information like name, age, gender, address, contact information, and National Provider Number (NPI). NPI verifies your registration status with the practicing licensing boards. Now, this profile acts as a centralized data repository for customers and payers.
2. Complete & Submit
Once registration is done, educational and training information is needed. Great care and attention should be given while submitting the information. Any type of error or incomplete information can lead to application rejection. This platform provides you with a structured format, and you just need relevant information in each section. Data that should be submitted on the CAQH platform is:
- Personal details
- Educational history
- Work history
- Licenses & certifications
- Professional liability insurance
- Hospital affiliations
- Board certifications
- Disciplinary actions
- Peer references
3. Maintain Profile Updates
Healthcare professionals need to visit their profiles periodically for additional information about their ongoing studies or training. If they obtain any new license or certification, they need to update their profile so that credentials and payers can review such information. CAQH sends reminders to healthcare professionals for profile updates after every 120 days. This step is very important to remain compliant with credentialing policies and regulations.
4. Authorize Access to Payers
The provider profile is not public and only allows limited people to check their information. After completing and submitting a profile, they need to authorize specific authorities to view their CAQH profile. This is important because multiple hospitals and insurance companies can view a provider’s profile information at once. There is no need to provide separate information to each concerned party.
Benefits of using CAQH for Credentialing
Widely Accepted
More healthcare providers apply for credentialing every year than the previous year. This makes it difficult for hospitals to credential huge amounts of applications using traditional methods for data verification. Even chances of errors and omissions are increased due to the high application load. However, CAQH has centralized data, and the credentialing process can be done online without any paperwork, reducing workload. Verification is also done automatically, reducing credentialing costs and resources.
Reduce Administrative Burden
CAQH platform is widely accepted and recognized by credentialing bodies, insurance companies, and healthcare professionals across the US. From major hospitals to basic health units, all health plans and networks use CAQH for credentialing. This broad acceptance streamlines the process more effectively, and all credentialing steps, like primary source verification, can be done in no time.
Enhance Data Accuracy & Compliance
What is the purpose of CAQH credentialing? CAQH makes sure that the uploaded data is accurate and up-to-date for credentialing. This actually complies with data management regulations set by NCQA. Accurate and correct data is assessed. Excuses for filling in inaccurate data or copying wrong information are also excluded, as data is directly taken from the website. This acts as a bridge between providers and credentialers to build trust and ensure transparency.
Tracking of Credentialing Status
Generally, credentialing takes days and even months, and then, providers are able to know the decision of the credentialing committee. But thanks to CAQH, credentialing has become superfast. Even healthcare providers can track the real-time status of processes. This enhances transparency and allows providers to estimate the duration of credentialing. This also helps hospitals to check new hires and candidates for credentialing. Better planning and smooth execution can be done using CAQH platforms.
Conclusion
CAQH is the Council for Affordable Quality Healthcare, and it helps the healthcare sector in terms of data integration and security. It is a non-profit organization that provides various platforms for data storage and management and streamlining of various processes like credentialing. How to use CAQH for credentialing?
It can be used by providers, credentialers, and payers. Providers need to register themselves on CAQH ProView, submit their data, and provide access to concerned authorities like payers and credentialing committee members. They can seek information used in the credentialing process and get primary source verification directly done. This quickens the credentialing process and reduces costs and other resources. All parties can check the status of the credentialing applications as well.
FAQ - People Also Asks
As CAQH is widely accepted by many healthcare organizations and providers, it is recommended that all providers have a CAQH profile. Even though not all organizations require it, this profile simplifies and speeds up the credentialing process.
CAQH sends reminders to providers every 120 days to attest the information on their profile. They can also submit data if any significant changes occur in licenses or training certifications.