Credentialing Corner

# Do You Have The Necessary Credentials For Medical Credentialing

- January 13, 2025
- Posted by Kristen Edwards

07 Mar

Medical Credentialing is an official system through which the health care providers verify the qualifications, professional experience, and medical training. The process is essential because it ensures that the healthcare workers are well-equipped with the necessary skills and exhibit behavior that will be safe and efficient while serving the patients.

Applicants need essential documents, which we call credentials, to undergo this process. Applicants are encouraged to maintain all the original verified credentials for a successful process.

In this article, we will discuss the primary credentials needed for the medical credentialing process, the importance of having the required credentials, and the process of credentialing. Also read our blog for Medical Specialties vs. Sub-Specialties credentialing.

## Types of credentials

### 1. Medical Degrees

Medical degrees like MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine) are the basis of any healthcare provider’s education. These degrees usually come after a complete medical school program that consists of classroom work, clinical rotations, and exams. Hence, medical degrees give healthcare providers a basic understanding of identifying, treating, and managing different health problems.

### 2. Certifications

On the other hand, board certifications are specific qualifications that validate an individual healthcare provider’s specialization in a particular area(s) of medicine. Besides, these certifications are mainly acquired upon completion of residency programs for certain specialties with subsequent examination by an approved medical board. As a result, this is demonstrated by their continuous learning and professional development as they acquire these certifications to keep them updated on the latest medical innovations in their field.

### 3. State Licenses

Healthcare providers need state licenses to practice medicine legally in a particular state. These are issued by the board of medicine and are based upon specific educational, training, and examination requirements met by the provider. State licenses safeguard patients, ensuring that they obtain care from capable and competent healthcare professionals who adhere to the regulations and standards of practice set forth by the state.

### 4. Specialist Training

Certifications or further training in some areas of medicine can also be seen as an additional medical credential. Such programs equip healthcare providers with other knowledge and skills in specialized fields, thus enabling them to offer specialized care to patients. Usually, specialty training is pursued by healthcare providers who want to enhance their expertise in a particular field of medicine or take up careers in academia or research.

### 5. Employment History

Job History will also contain details of dates of employment, position held, and role carried out. Employment history also includes feedback from previous recruiters to judge healthcare providers’ competence and professional behavior.

### 6. HIPAA training

Documented proof of HIPAA training, which healthcare institutions might need to guarantee patients’ adherence to privacy rules.

## Why is maintaining credentials necessary?

Medical credentials are crucial in medical credentialing as they ensure that healthcare providers have the skills and experience to care for patients safely and effectively. By way of checking healthcare professionals’ licenses, medical credentialing helps uphold the quality and safety of healthcare services. The importance of medical credentials is described as follows:

### Ensuring quality and safety of patient care

License updates are the cornerstone of professionalism, and these help offer the safe management of health systems. A healthcare provider often uses references like board certifications and specialty skills to show their expertise in a specific branch of medicine, thus indicating that they are sufficiently qualified to give patients an adequate standard of care.

### Meeting credentialing requirements of healthcare organizations

Credentialing of medical doctors is a mandatory requirement for the providers to be granted the opportunity to practice medicine in healthcare organizations. A lack of upkeep on these credentials may lead to refusal or even revocation of one’s privileges and prevent the healthcare provider from practicing in the organization.

### Avoiding legal and ethical Issues

Medical licenses should be renewed regularly for healthcare providers to avoid liabilities and ethical conflicts. Using fictitious or false credentials can lead to prosecution in the courts, including both civil and criminal liabilities.

## Understanding of the Medical Credentialing Process

Application: There is an application stage where the candidates provide their qualifications, background information, and work experiences to the credentialing body.

Verification: There is a verification phase where an organization proves if what has been submitted by a health provider is correct regarding qualification, education history, or employment records, among other things.

Review: It is another step during which the committee examines all documents supporting the application form concerning whether the applicant’s credentials are up to standard.

Decision: After reviewing the applicant’s file carefully, the committee makes a final decision about granting a practicing license.

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## Additional credentialing documents for New Physicians

1. Personal Information: Your address, e-mail, telephone number, etc.. that will be given personally to you.
2. Driver’s License: A copy of your valid driver’s license.
3. Social Security Card: Please attach the original copy of your Social Security card.
4. Recent Photograph: A recent picture of your front or back signature should be attached, signed, and dated in the margin.
5. Medicaid Number
6. Medicare Number
7. National Provider Identifier (NPI#) Documentation: Submit the original NPI documentation and generate a confirmation letter as your submission.
8. UPON Number: From what we understand.
9. Federal Tax ID Number: EIN (Employer Identification Number) — FEIN (Federal Employer Identification Number)
10. Permanent Resident Card/Green Card/Visa: If you are a non-US national, copy of your Permanent Resident Card (Green Card), Visa status, or any others.
11. State License Wallet Card and Wall Certificate: Copies of all the current mining state license wallet card(s) and wall certificate(s) with the expiration date and the number.
12. Federal DEA and State Controlled Substance Registrations: Copies of issued Federal DEA and State controlled substance registrations or certificate(s).
13. Medical School Diploma and Training Certificates: Tell the employer all the certificates you collected during your studies, including the medical school diploma, certificate of training and internship certificate, residency certificate, and fellowship certificate.
14. Board Certificate: A photocopy of your Board Certificate with the name of the board and the dates of credentialing and re-credentialing provided.
15. Surgical Logs: Surgical records.
16. Hospital Privileges: Documenting Privileges of the hospital.
17. Delineation of Privileges Form: Outline of privileges was filled in the Privileges Delineation Form.
18. Locum Tenens Practice Experience Form: Have completed a Locum Tenens Practice Experience Form (if required).
19. Third-Party Documentation: Third-party documentation (court records/disposals) for all malpractice/disciplinary actions OR filling out an appropriate explanation form (if there be any).
20. Professional Liability Insurance Coverage: Certificate of Professional Liability Insurance or an insurance policy’s face sheet (if applicable).
21. Case Logs: Case logs (from the last 24 months, if possible).
22. Letters of Recommendation: Three well-written letters of recommendation from providers they have closely worked with within the past year.
23. ACLS/BLS Certification: First-aid/CPR card.
24. Copy of DEA certificate
25. Current CME
26. Residency Diploma: Original copy of secondary school diploma.
27. Military Discharge Record (if applicable).
28. NBME/FLEX/USMLE/SPEX Scores
29. Additional Certificates: Copies of the front and back of any BLS, ACLS, ATLS, PALS, APLS, or NRP certificates.
30. ECFMG Certificate: If the graduate is from abroad, you must provide your ECFMG number.

## Conclusion

Credentials are like the real identity of the healthcare providers as they identify their educational background, ethical values, and expertise level. Maintaining credentials for the medical credentialing process is necessary to get a job as a healthcare professional. It is recommended for physicians and other healthcare staff to keep their credentials safe and up-to-date to avoid any irregularities in the credentialing process.

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