Credentialing dictionary
Glossary
Plain-language definitions of credentialing and enrollment terms.
A
ABMS
The American Board of Medical Specialties is the umbrella organization of member boards that certify physician specialties and serves as a source for verifying board certification.
Attestation
A provider's signed confirmation that the information in their credentialing profile is accurate and complete as of a given date.
B
C
CAQH
CAQH ProView is an online repository where a provider maintains a single profile of demographic, licensure, education, and work-history data that health plans can access with authorization.
CAQH
The Council for Affordable Quality Healthcare, a nonprofit alliance whose ProView database is the de facto universal provider data source for U.S. health plans.
Certificate of Insurance (COI)
A document that evidences a provider's malpractice coverage, including policy limits and effective dates.
Clean Claim
A claim submitted without errors or missing information that a payer can adjudicate and pay without requesting anything further.
CME (Continuing Medical Education)
Ongoing educational credits clinicians must earn to maintain licensure and board certification.
Collaborative Practice Agreement
A formal agreement defining a supervising or collaborating physician relationship required for some NPs and PAs under state law.
Compact License
A professional license obtained through a multi-state compact, such as the IMLC for physicians or the NLC for nurses.
Continuous Query
Continuous Query is an NPDB enrollment that automatically alerts an organization whenever a new report is filed on an enrolled practitioner.
Credentialing
The process of verifying that a provider holds the qualifications, licensure, and history they claim before granting network participation or privileges.
Credentialing Committee
The credentialing committee reviews verified provider files and recommends approval of network participation or clinical privileges.
CVO
Credentials Verification Organization — an entity that performs primary source verification on behalf of health plans, hospitals, and groups.
D
DEA Registration
A registration with the U.S. Drug Enforcement Administration that authorizes a provider to prescribe or dispense controlled substances.
Delegated Credentialing
An arrangement in which a health plan delegates its credentialing verification to another qualified entity, such as a group or CVO, under a formal agreement.
E
F
G
H
I
L
M
Malpractice Insurance
Professional liability coverage carried by providers, whose certificate or face sheet is a standard document collected during credentialing.
Medicaid Enrollment
The process of enrolling a provider to participate in a state Medicaid program, with requirements that vary from state to state.
Medical Staff Office
The Medical Staff Office is the hospital department that manages credentialing, privileging, and reappointment of the medical staff.
Medicare Enrollment
The process of enrolling a provider so they can bill and be reimbursed by Medicare, completed through PECOS.
N
NCQA
The National Committee for Quality Assurance, an accreditation body whose credentialing standards many U.S. health plans and CVOs follow.
Network Adequacy
Regulatory standards requiring a health plan to maintain enough in-network providers for reasonable member access.
NPDB
The National Practitioner Data Bank is a federal repository of malpractice payments, adverse actions, and sanctions that is queried during credentialing.
NPI
National Provider Identifier — a unique 10-digit number assigned to covered health care providers in the United States.
NPPES
The National Plan and Provider Enumeration System is the CMS system that issues National Provider Identifiers and maintains the public provider record.
O
OIG Exclusion
A determination by the U.S. Office of Inspector General that bars an individual or entity from participating in federal health care programs.
OPPE
Ongoing Professional Practice Evaluation is a Joint Commission requirement to continuously review privileged practitioners, commonly about every six months.
P
Participating Provider
A provider who has signed a contract with a health plan to deliver services in-network at agreed rates.
Payer Enrollment
The process of establishing a provider in a health plan's systems so the provider can participate in-network and have claims paid.
PECOS
The Medicare Provider Enrollment, Chain, and Ownership System used to enroll providers and manage their Medicare enrollment records online.
Pre-Delegation Audit
A health plan's review of an organization's credentialing program before allowing it to perform credentialing on the plan's behalf.
Primary Source Verification
The process of validating a provider's credential directly with the original issuing source, the foundation of defensible credentialing.
Privileging
The facility-level process of authorizing a credentialed provider to perform specific procedures or services based on their training and competence.
Provider Data Management
The continuous work of keeping a provider's demographic, credential, and contact information accurate and consistent across every system that relies on it.
Provider Directory
A payer's public listing of in-network providers, whose accuracy is regulated and tied directly to roster data.
Provisional Credentialing
Provisional credentialing is temporary or expedited credentialing that grants limited or time-bound participation while full credentialing is completed.
PSV
Primary Source Verification — confirming a credential directly with the issuing authority rather than relying on a provider-supplied copy.
R
Re-Credentialing
The periodic re-verification of a provider's credentials, commonly required at least every three years to maintain network participation or privileges.
Reappointment
Reappointment is the periodic re-evaluation of a privileged provider at a facility, commonly occurring about every two years.
Retroactive Billing
Submitting claims for services dating back to a retro-effective date after enrollment is approved, where the payer permits it.
Revalidation
Medicare's periodic requirement that enrolled providers reverify and update their enrollment information, commonly on a five-year cycle.
Roster
A structured list of providers exchanged between a group and a payer to add, update, or terminate providers in bulk.
S
SAM Exclusion
Exclusion records in the federal System for Award Management, screened alongside the OIG LEIE to identify parties debarred from federal programs.
Sanctions Screening
The ongoing checking of providers against federal and state exclusion and sanction lists, such as the OIG LEIE, SAM, and state databases.
Scope of Practice
The set of procedures and actions a provider is legally authorized to perform under their license and state law.
State Medical Board
The state authority that licenses and disciplines physicians and serves as the primary source for license verification.
T
Tail Coverage
Extended reporting coverage that protects against claims filed after a claims-made malpractice policy has ended.
Tax ID (TIN)
The tax identification number under which a provider or group bills, linking the rendering provider to the correct billing entity during enrollment.
Taxonomy Code
A standardized HIPAA code that classifies a provider's specialty, type, and area of practice and is associated with their NPI.
The Joint Commission
A widely recognized accreditation organization whose standards shape how hospitals credential, privilege, and monitor their providers.
Type 1 NPI
The National Provider Identifier issued to an individual healthcare provider, such as a physician or nurse practitioner.
Type 2 NPI
The National Provider Identifier issued to an organization or group, such as a clinic, hospital, or practice entity.