The Role of CAQH in Credentialing and How to Keep It Updated

Healthcare credentialing is already a complicated process with forms, payer requirements, and deadlines. To simplify things, the Council for Affordable Quality Healthcare (CAQH) was created as a centralized database where providers can save their professional and practice information. Providers no longer need to submit duplicate documents to different insurance companies; instead, they can maintain a single CAQH profile, and insurers can access the necessary information from it.

In medical practices, physicians, nurse practitioners, and other healthcare professionals consider CAQH to be an essential part of the credentialing and enrollment process. However, despite its importance, many providers do not understand how CAQH works or fail to keep their profiles updated, leading to delays, denials, and revenue loss.

This guide will explain what CAQH is, how payers use this tool in credentialing, how to set it up, and, most importantly, how to maintain it properly. Hence, your practice avoids any unnecessary credentialing problems.

What is CAQH?

CAQH is an abbreviation of Council for Affordable Quality Healthcare, which is a non-profit organization that partners with payers and healthcare providers to facilitate administrative workflow. The CAQH ProView database is one of their most valuable tools.

ProView enables healthcare providers to input their professional information, licenses, certifications, practice history and malpractice history, and other needed information in one place. This information is, in turn, accessed by insurance companies to provide credentialing of providers and keep their records up to date.

Before the pre-CAQH era, providers filled out separate paper applications, often answering the same questions multiple times for payers. CAQH was designed to eliminate duplication and save time, while improving accuracy in the credentialing process.

Why CAQH Matters in Credentialing

Credentialing is the process by which insurers review a provider’s qualifications, such as licensure, education, work history, malpractice, and compliance. Insurance companies rely on this information to decide whether a provider can join their network and earn reimbursements. Without a CAQH profile, providers face a longer and more manual enrollment process. However, with CAQH, payers can directly access provider information, making the process faster and more consistent.

Among the principal reasons why CAQH is important in credentialing, we have:

• Efficiency: The same CAQH profile can be used through many payers.
• Precision: Providers manage their information and update it in real-time.
• Compliance: Compliance with your insurer mandates the use of CAQH for credentialing and recredentialing.
• Revenue Protection: A CAQH profile that is outdated or missing CAQH profile will delay enrollment, resulting in claim denials.

How Payers Use CAQH

In applying for insurance credentialing or re-credentialing, most payers will request your CAQH ID first. They are allowed to log in to the system and access your information once you give them consent.

Payers use CAQH to do the following:

• Cross-check that your employment information is consistent with this application.
• Make sure of your practice locations and group affiliations.
• Check that your licenses, DEA, and board certifications are still current.
• Check your malpractice insurance coverage
• Look at gaps or inconsistencies in your work history.

Incomplete or inaccurate CAQH profiles could mean that payers may pause or deny your application, and you must update your profile before proceeding. This may take weeks or even months to complete the credentialing process.

How to Set Up a CAQH Profile

The initial setup of CAQH may seem overwhelming; however, once it is in place, it makes credentialing very effective. This is how it works:

1. Get Your CAQH ID

Other insurance providers will automatically generate a Type of CAQH Provider ID when you apply for credentials. Otherwise, you can register directly on the CAQH website.

2. You need to complete the CAQH application.

You will have to provide detailed information and include:

• Contact and personal data
• History of education and training
• DEA certification and state licenses
• Malpractice insurance information
• History and affiliations in work and practice
• Hospital privileges (as appropriate)

3. Submit Supporting Documentation

You are also required to upload documentation:

• Current malpractice certificate
• Board certification
• DEA license
• State medical license

4. Authorize insurers to view your profile

Payers cannot see your CAQH file unless you authorize it. This is a typical error that many providers fall into, and delays occur.

5. Attest Your Profile

Last but not least, you will need to witness that your data is accurate. Even in the case when nothing changed, attestation has to be renewed every 90 days.

Common Issues with CAQH

Although CAQH is meant to ease the process of credentialing, several providers end up with issues, including:

• Expired Documents: Failure to upload updated license or malpractice information.
• Missed Attestation: Not attesting every 90 days, which makes the payers believe that the profile is inactive.
• Incomplete Profiles: Leaving spaces empty, and/or not completing practice addresses properly.
• Authorization Errors: Failure to give access to payers to see the profile.
• Data Inconsistencies: Discrepancies between CAQH data and applications that are submitted to payers themselves.

All these problems may cause the credentialing to be delayed or result in claims rejections.

Tips to Keep CAQH Active and Accurate

Keeping your CAQH profile active is essential. These are some of the best practices:

1. Schedule Calendar Reminders

Re-attest within 90 days. Some providers forget, and their profiles turn dormant.

2. Update Whenever Changes Occur

If your practice address, malpractice insurance, or license changes, update CAQH immediately.

3. Up-to-date Documents

Provide new licenses, DEA certificates, or insurance policies before the expiration of the old ones.

4. Look at Consistency

Make sure your CAQH information is aligned to your payer application, your NPI information, and Medicare/Medicaid enrollment.

5. Consider Using Credentialing Services

Maintaining CAQH can be daunting, though, and professional credentialing services can handle your profile on your behalf and guarantee accuracy and timeliness.

Why Providers Must Take CAQH Seriously

CAQH is not a choice for providers. It is a requirement of almost all commercial insurance payers, and a number of hospitals use it during the credential verification process as well.

• In the absence of the current CAQH profile.
• Insurance processing may be delayed.
• Payments may be denied.
• You may experience interruptions in recredentialing.
• It may influence the level of your practice revenue.

Taking CAQH seriously doesn’t mean being a doormat for administrative forms again, but it does require that you see CAQH as a key business tool.

Conclusion: Streamline Your Credentialing with CAQH

The modern credentialing system for healthcare relies on CAQH. Centralizing provider data reduces loopholes and repetitive tasks for both providers and payers. However, its effectiveness depends on providers keeping their profiles current and accurate. When starting or maintaining your CAQH profile, remember that any discrepancies can directly affect your credentialing timelines, relationships with payers, and revenue cycle. To ensure efficiency and minimize errors, partnering with a professional credentialing organization like Credex Healthcare can help you keep your CAQH profile error-free and ready for review. Errors in CAQH cost you valuable credentialing time. To ensure your profile is accurate and your revenue continues to grow, contact Credex Healthcare today.

FAQs

1. What is credentialing CAQH?

CAQH is a centralized database where healthcare professionals store their information. It is used by insurance companies to verify provider information.

2. How frequently do I have to update CAQH?

You must re-attest every 90 days, even if no information has changed. New licenses, insurance policies, or practice updates must be uploaded as soon as they take place.

3. What happens when my CAQH is not active?

Your credentialing applications will not be processed by the payers, which causes delays or denials of your claims.

4. Are there other insurance companies that do not use CAQH?

Most large commercial carriers will need CAQH, but smaller or regional plans may still have their own process.

5. Is it possible to outsource CAQH management?

Yes. Professional credentialing services are preferred by many providers in order to keep up with CAQH updates, as well as uploading documents, update informations and re-attestations.