Hospital Privileging vs. Payer Credentialing: How the Two Processes Differ

What Payer Credentialing Involves

Payer credentialing is done by health insurance plans. Its goal is to decide whether a provider can join the plan's network, and its focus differs from a hospital's:

• It verifies qualifications, often relying on the CAQH ProView profile for commercial plans.
• It doesn't grant clinical privileges. Instead, it leads to network participation and a contract or a link to an existing group contract.
• It is tied to billing: the outcome determines whether the provider's claims are processed as in-network.

Many commercial plans follow NCQA credentialing standards, which generally call for recredentialing at least every three years.

Side-by-Side Comparison

Where the Processes Connect

Even though they are separate, the two processes affect each other:

• Payers may ask about hospital affiliations. Some plans ask about admitting privileges or require an explanation of how inpatient care will be handled if the provider doesn't have privileges.
• Facility-based providers need both. Hospitalists, anesthesiologists, emergency physicians, and radiologists usually can't work without privileges, and the hospital or their group usually needs them enrolled with payers before their services can be billed.
• Consistency matters. Inconsistent dates, addresses, or work history between a hospital application and a CAQH profile can lead to questions from either side.

Temporary, Telehealth, and Locum Tenens Providers

Not every provider follows the standard path of applying to one hospital and practicing there long term. Three situations come up often.

Temporary Privileges