By Optimus Billing Solutions Editorial Team · Published · Last reviewed
Key takeaways
- CAQH ProView is the profile payers read. It is not the application itself, and not every payer uses it.
- A provider must re-attest the profile regularly. A lapse can stall enrollment.
- Credentialing verifies the provider. Contracting sets the rates. They are separate steps.
- Start credentialing before the provider's start date, because unenrolled weeks are unpaid weeks.
What is CAQH credentialing?
CAQH credentialing is the process of building and maintaining a provider's profile in CAQH ProView so health plans can verify the provider's qualifications. CAQH is a nonprofit alliance of health plans and related organizations. Its ProView system stores one profile per provider, and the provider authorizes plans to view it.
The benefit is that a provider enters most of the data once, rather than on a separate form for every plan.
What goes into a CAQH ProView profile
A complete profile typically includes:
- Personal and practice information, including practice locations
- Education, training and board certification
- Active state licenses and DEA registration, where applicable
- Work history and any gaps, explained
- Malpractice insurance details
- Hospital affiliations
- An NPI, the National Provider Identifier, which you can look up or apply for through NPPES
- Supporting documents, such as copies of licenses and certificates
Keep the documents current. An expired license on file is a common reason a payer pauses an application.
Re-attestation: the part people forget
Providers must periodically confirm that the information in their profile is accurate, which CAQH calls re-attestation. CAQH asks providers to re-attest every 120 days. Miss it and a health plan may no longer be able to rely on the profile, which can stall an application or put an existing enrollment at risk.
Put the date on a shared calendar, not in one person's memory.
CAQH, NPI, PECOS and enrollment: how they fit together
- NPI identifies the provider. Everything else refers to it.
- CAQH ProView holds the credentialing data many commercial plans read.
- PECOS is Medicare's Provider Enrollment, Chain and Ownership System, used for Medicare enrollment.
- Payer applications are the individual plan forms and requirements. Some require CAQH, some require their own portals.
Credentialing is also not contracting. Credentialing verifies the provider. Contracting sets the rates and terms the plan pays. A provider normally needs both before in-network claims are paid at contracted rates.
Where practices get stuck
- Applying after the provider has already started seeing patients
- Gaps in work history with no explanation
- Expired documents in the profile
- Missed re-attestation
- Nobody owning the follow-up with each payer
Timelines are set by payers, not by the practice or by us, so the practical answer is to start early and follow up on a schedule.
When to do it yourself and when to hand it off
If you are credentialing one provider with one or two plans and you have the time, doing it yourself is reasonable. If you are adding several providers, joining many plans or you have been waiting on approvals, handing it off pays for itself in follow-up alone. At Optimus, credentialing is from $100 per payer plan.
When outsourcing credentialing is not the right fit
If a provider is not yet licensed in the state, applications cannot start. And if you need payer contract negotiation, that is a separate service from credentialing.
How Optimus handles credentialing
We set up and attest the CAQH profile, complete each payer application, follow up until the payer responds and track renewals afterward. See credentialing services or the free billing audit.
This article is general information, not legal or compliance advice. Payer rules and regulations change, so confirm current requirements with the payer or the governing agency.