Credentialing: The process of obtaining, reviewing, and verifying a provider's credentials—the documentation related to licenses, certifications, training, and other qualifications—for the purpose of determining whether the provider meets the MCO's preestablished criteria for participation in the network.

 

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Credentialing: The process of obtaining, reviewing, and verifying a provider's credentials—the documentation related to licenses, certifications, training, and other qualifications—for the purpose of deter . . . View Full Definition

Credentialing Committee: Committee, which may be a subset of the QM committee, that oversees the credentialing process.

Recredentialing: Reexamination by an MCO of the qualifications of a provider and verification that the provider still meets the standards for participation in the network.

Primary Source Verification: A process through which an organization validates credentialing information from the organization that originally conferred or issued the credentialing element to the practitioner.

Health Care Quality Improvement Act (HCQIA): A federal act which exempts hospitals, group practices, and HMOs from certain antitrust provisions as they apply to credentialing and peer review so long as these entities adhere to due proc . . . View Full Definition