Health Plan Provider Credentialing: A Beginner’s Guide

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In the field of healthcare, proper credentialing is crucial. Health plan providers must meticulously verify credentials, or risk legal and financial repercussions. When it comes to health plans, the quality of healthcare services provided is paramount. Clients carefully consider the expertise and experience of practitioners when choosing a health plan. Therefore, it is the responsibility of the health plan provider to ensure that the practitioners’ qualifications and actual skills align.

At andros, we provide comprehensive medical credentialing services to health plan providers who want to delegate this complex process to an experienced team. Beyond credentialing, our expertise also extends to end-to-end provider network management services. Partner with us for a comprehensive solution to healthcare provider management and credentialing that prioritizes service, quality, and patient satisfaction.

Why Credentialing is Important for Health Plans

In the constantly evolving healthcare industry, having a robust credentialing process in place is crucial for health plan providers and insurance companies. Credentialing plays a vital role in delivering affordable and quality healthcare to patients.

At andros, we understand the significance of a robust credentialing process and offer valuable solutions to meet the needs of health plan providers.

Ensuring Provider Competence and Qualifications

By implementing credentialing, health plan providers can thoroughly verify the competence and qualifications of healthcare professionals seeking to join their network. This includes a review of:

  •   Educational history
  •   Training
  •   Licensure
  •   Certifications
  •   Work history

This approach ensures that only qualified healthcare providers become part of your network, maintaining high standards of care and fostering patient trust.

Compliance with Regulatory Requirements

Credentialing allows health plan providers to comply with regulatory requirements set by government bodies. By conducting thorough credentialing, health plan providers can demonstrate their commitment to meeting these requirements. This doesn’t just help maintain your reputation but also allows you to mitigate legal risks.

Enhancing Patient Safety and Satisfaction

A robust credentialing process directly contributes to patient safety and satisfaction. By verifying providers’ credentials, health plan providers make sure that patients receive care from qualified professionals.

This helps build trust and confidence among patients, leading to higher patient satisfaction rates and better retention.

Improving Network Integrity and Provider Collaboration

Credentialing allows health plans to maintain the integrity of a health plan provider’s network. By carefully evaluating providers’ credentials, you can make sure that your network consists of reputable professionals.

This fosters collaboration and promotes a culture of excellence within the network,  benefiting both patients and providers. 

With our comprehensive solutions, health plan providers can ensure network integrity and enjoy the benefits of strong provider collaboration.

With andros, health plan providers gain access to advanced credentialing software, expert verification specialists, and a vast network of reliable data sources. Our tailored solutions ensure a smooth provider credentialing process.

Recommended Credentialing Process

At andros, we understand the critical role that high-quality credentialing plays in the healthcare industry. As a trusted Credentials Verification Organization (CVO), we offer meticulous verification for your network members, ensuring their qualifications are thoroughly checked. 

Credentialing Application and Documentation Review

The first step in our credentialing process involves a thorough review of the provider’s application and supporting documentation. This includes checking:

  •   Personal information
  •   Education
  •   Licenses and certifications
  •   Work history

We also pay close attention to any red flags, such as malpractice history and disciplinary actions.

Primary Source Verification

To maintain the highest level of accuracy, we conduct primary source verification (PSV) for all credentials. By directly contacting issuing authorities, educational institutions, licensing boards, certification bodies, and previous employers, we determine the authenticity of provided information. With an extensive network of trusted sources, we can quickly generate PSV. 

Peer References

Our team also reaches out to peer references provided by the healthcare professional. By contacting individuals who have worked closely with the applicant, we gather valuable insights into their competence.

In our experience of providing CVO services to various health plans, peer references play a crucial role in evaluating the applicant’s ability to provide high-quality care.

Ongoing Monitoring

Medical credentialing is not a one-time event but an ongoing process. We implement a robust monitoring system that includes regular re-verification according to a pre-set schedule.

You don’t need to worry about medical providers from your network experiencing downtime due to untimely accreditation. Our team stays on top of the process.


We offer detailed reports to the health plan, outlining our findings and recommendations. These reports equip you with the necessary information to make informed decisions about network participation. Our aim is to deliver precise and prompt data to aid the health plan in making credentialing decisions and expedite the provider enrollment process.

Health Plans Often Face Credentialing Challenges 

Arranging provider credentialing for health plans can be a challenging process. At andros, we understand the common issues that health plan providers encounter and offer effective solutions to address them.

Time-Consuming Process

Credentialing requires significant time and resources to verify the necessary documentation, conduct primary source verifications, and review applications. This can be a burden for health plan providers who already juggle numerous responsibilities.

andros streamlines the provider credentialing process. By leveraging advanced technology and experience, we expedite the process and alleviate the administrative burden.

Compliance with Regulatory Requirements

Health plan providers must comply with various regulatory requirements when credentialing providers. Staying up-to-date with changing regulations and ensuring compliance can be challenging.

andros stays on top of the latest regulatory changes to make sure that the credentialing process aligns with the current requirements. By partnering with our team, you can avoid non-compliance, fines, and downtime.

Lack of Expertise and Resources

Credentialing requires specialized knowledge and expertise to navigate the process. Many health plan providers lack the in-house resources to conduct thorough credentialing.

andros brings extensive experience and a team of highly skilled professionals who are well-versed in credentialing best practices. We provide the necessary resources to ensure comprehensive credentials verification.


Outdated or inefficient credentialing can lead to delays and unfortunate errors. At andros, we arrange a streamlined process to eliminate inefficiencies and improve the overall credentialing experience.

Our technology-driven solutions enable seamless data collection, verification, and reporting. This reduces the risk of errors and improves provider enrollment efficiency.

Timely Recredentialing

Credentialing isn’t a one-time task. It involves continuous monitoring. Re-credentialing in a timely manner can be a challenging task for health plan providers to handle internally.

With the andros team at the helm, you can be sure that re-credentialing is in professional hands. We make sure all your providers pass re-credentialing on time.

How to Simplify Health Plan Credentialing

At andros, we strive to simplify the credentialing process for health plan providers. Here’s how:

Streamlined Application Process

Our application system is designed to minimize provider input. Whether we receive data through an API, batch upload, or a provider-filed application, our system identifies the required data to complete the NCQA-certified credentialing process.

With a robust repository of verified data, we autofill provider information, reducing the chances of incorrect submissions. Our application takes only 20 minutes to complete.

Automated Primary PSV

Our platform automates processes that can take hours or even days to complete manually. Data-matching algorithms provide instant primary source verification while identifying any gaps or potential roadblocks such as malpractice, licensure, or sanctions issues. This saves time and ensures a thorough provider credentialing procedure.

Trained Professional Oversight

Our team of trained credentialing professionals steps in when discrepancies arise. They reach out to providers and facilities multiple times to check flagged issues and perform quality checks. We never miss any red flags and always try to resolve problems as fast as possible.

After provider credentialing is complete, you receive an easy-to-read profile containing vital healthcare provider information. We provide comprehensive credentialing reports in your preferred format. This enables efficient final review and approval processes while eliminating the need for overwhelming paperwork.

Health Plan Credentialing Case Studies

Over the past years, andros has helped multiple health plans and insurance companies with insurance credentialing and provider network management. Humana Inc is one of these companies that had to deal with a large number of providers but didn’t have sufficient time to arrange a robust insurance credentialing process.

The andros team helped the insurance company identify potential compliance issues and mitigate them before they turned into costly problems. After choosing andros as their CVO partner, the time it took to complete credentialing for Humana providers decreased by 300%! 

Medical credentialing is a complex process that requires experience, expertise, and special skills. At andros, we work with health plan providers who need a robust solution to their credentialing and network management issues. We can help you achieve your goals, cut costs, improve your insurance credentialing process, and enjoy a healthy operations environment.

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