What Are the 5 Primary Types of Healthcare Credentialing? (2025 Guide Explained)
Insurance Credentialing (Payer Enrollment)
Hospital Privileging and Credentialing
State Medical Board Credentialing
Facility Credentialing
Telehealth Credentialing
Insurance credentialing, also known as payer enrollment or provider enrollment, is the process of becoming an approved provider with insurance networks such as Medicare, Medicaid, Aetna, BCBS, Cigna, and UnitedHealthcare. Without it, providers are considered out-of-network and cannot bill for services.
Insurance Credentialing Requirements
Active state license and NPI registration
Malpractice insurance coverage
Verified education and residency history
Complete work history with no unexplained gaps
No disciplinary or legal issues
Credentialing Tools
State-specific provider portals
2. What Is Hospital Privileging and Credentialing?
Hospital credentialing, also known as clinical privileging, is managed by the Medical Staff Office and reviewed by a credentials committee. It authorizes providers to perform specific clinical duties based on their qualifications.
Hospital Credentialing Requirements
Medical school transcripts
Verification of board certifications
Procedure logs and case histories
Peer references
National Practitioner Data Bank (NPDB) query
⏳ Privileging must be renewed every 2–3 years, especially for surgical and procedural specialties.
3. What Is State Medical Board Credentialing?
Every provider must hold a valid license with the state medical board where they practice. This credentialing ensures that providers meet professional and ethical standards.
Key Requirements
State license application and renewal
Fingerprinting and criminal background checks
Primary source verification (education and training)
Exam records (USMLE, COMLEX, NBME)
CME (Continuing Medical Education) documentation
⏳ Renewal cycles vary by state, typically 1–3 years.
4. What Is Facility Credentialing?
Facility credentialing applies to group practices, behavioral health centers, ambulatory surgery centers (ASCs), and other organizations that bill under a group NPI. It ensures compliance with safety and operational standards.
Facility Credentialing Verifies
OSHA and HIPAA compliance
Liability insurance coverage
Fire and safety inspections
Ownership and leadership structure
➡️ Without facility credentialing, organizations cannot bill under their group entity.
5. What Is Telehealth Credentialing?
Telehealth credentialing has grown rapidly with the expansion of virtual care. It ensures providers are properly licensed and compliant when delivering services across state lines.
Telehealth Credentialing Requirements
HIPAA-compliant telehealth platforms
Multistate licensure for interstate practice
Documentation of telehealth training (if required by payers)
Correct claims coding (POS code 02/10 with modifier -95)
💡 Providers in IMLC (Interstate Medical Licensure Compact) states benefit from simplified multistate licensing.
What Are Common Credentialing Mistakes and Their Consequences?
| Mistake | Consequence |
|---|---|
| Incomplete applications | Delayed approval or payer rejection |
| Missed recredentialing | Removal from insurance panels |
| Outdated license/NPI info | Denials, legal risk, claim recoupments |
| Missing documentation | Delayed or denied hospital privileges |
| Not tracking expirations | Billing lapses, auto-deactivation by payers |
⏳ Credentialing usually takes 60–180 days. Planning ahead is essential to avoid costly disruptions in reimbursement and patient care.
FAQs About Healthcare Credentialing
Q1. How long does healthcare credentialing take?
Credentialing typically takes 60 to 180 days, depending on the payer, state, and completeness of the application.
Q2. What is the difference between credentialing and privileging?
Credentialing verifies a provider’s qualifications, while privileging authorizes them to perform specific procedures in a hospital or facility.
Q3. Do all providers need insurance credentialing?
Yes, any provider who wants to bill Medicare, Medicaid, or commercial insurers must go through payer enrollment.
Q4. Who handles credentialing in hospitals?
Hospitals have a Medical Staff Office (MSO) and a credentials committee that review provider applications.
Q5. Can credentialing be done for multiple states at once?
Yes. Providers in IMLC-participating states can apply for multistate licenses through a streamlined process.
