The Building and Flow of Health Care Credentialing

There is a flow in which the initial medical credentialing is done. Within the flow, there are four steps: step one the national level, step two the state level, step three the local level and step four the regional level.  Each step is built upon the previous step, creating a work flow in which this process is completed.  Like regular steps these steps must continually looked over so they function properly.

Step one is the national level. The follow items are building blocks to this step and must be completed:  National Provider Identifier number, medical credentialing portfolio, DEA license, Malpractice Insurance, board certification or a letter stating you’ve been granted to sit for your specialty boards, and a self-query to the National Practitioner Data Bank.

Step two is the state level.  There are only two building blocks to this level but in order for it to go smoothly the above step should be built and the information placed in your medical credentialing portfolio.  The two blocks are your state medical license and if required by the state and applicable to your specialty your state controlled substance license.

Step three is the local level.  To start this step it is required for you to have completed both steps one and two.  The local level steps building blocks are hospital and clinical privileges.  The clinic privileges is most likely where you will be practicing, they need to have a full copy of your medical credentialing portfolio on file so they may be a certified facility.  The clinic where you choose to practice will let you know where you need to receive hospital privileges, this is where you’ll need to apply for hospital privileges.

The fourth step is the regional level.  You’ll need to have your clinical privileges and information to apply for third party payer reimbursement.  This level is an extensive level in paperwork and the credentialing specialist at your practicing facility may help you with this endeavor.

As you build and complete each step of the credentialing process, the downward flow of third party reimbursement will follow.