CAQH And Everything You Need To Know About It


New to the healthcare space and unsure of what CAQH is? Good news, we’re here to give a detailed introduction of CAQH and why it should matter to healthcare professionals. This article defines what is CAQH, exactly, its role in the healthcare industry and why CAQH medical credentialing is important for healthcare practitioners and healthcare organizations.

What Is CAQH?

CAQH stands for the ‘Council of Affordable Quality Healthcare.” CAQH is an online information repository of medical credentialing information. "CAQH Medical Credentialing" refers to records in which doctors and practitioners self-report on their:

·         Education

·         Training provided,

·         History and nature of work,

·         (Potential) history of negligence or malpractice if any, and

·         Other important credentialing data.

All of this data is used to make a web-based medical credentialing profile for insurance agencies to access and evaluate. Electronic admittance of this data is intended to reduce the volume of administrative work by taking out a significant volume of paper-based information and transforming it into online data to benefit both the staff and medical front office.

What Is The Purpose Of CAQH?

As a non-profit, CAQH is not driven by the business of healthcare. Its objective is to reduce the time and cost of accessing critical information within the healthcare industry—specifically between healthcare plans and healthcare providers. (i.e. between insurance companies and clinics and/or healthcare practitioners).

In its efforts, it attempts to eliminate repetitive and wasteful information cycles and processes between healthcare plans and healthcare service providers for credentialing, maintenance of directories, coordination of advantages and other important business functions.

CAQH Services

The CAQH Committee On Operating Rules for Information Exchange (CORE) unites the healthcare industry, automating the collaboration between stakeholders, and making the exchange of business data and ideas, accurate and predictable. CAQH Committee on Operating Rules for Information Exchange (CORE) Certification is the industry's well trusted seal of endorsement to recognize associations that satisfy the highest standards for electronic information trade.

CAQH Explorations explores opportunities to decrease the overall burden of manual processes in healthcare organizations. Reducing the burden will mean there is more time to spend effectively on patient care and client servicing. Every year, the CAQH Index measures the industry's advancement toward a more computerized and proficient healthcare framework. This gives a brief insight on what CAQH is and the role played by CAQH.

A definitive goal of the Council for Affordable Quality Healthcare (CAQH) is to assemble medical credentialing data on healthcare specialists and make that data accessible to healthcare plans and other healthcare elements to smooth out the medical credentialing cycle. Fewer iterations, fewer conflicting processes, and speedier execution.

Healthcare service providers need to apply to and be acknowledged by the insurance agency to fit the bill for benefits. The process of application for medical credentialing is a rigorous one, which requires a many detailed application forms, documentation and information of the healthcare service provider.

Many healthcare providers find the application process tedious. Every protection carrier's application process is unique and may require different details as the criteria of evaluation may be different.

What the CAQH ProView Profile will do is introduce questions relevant to your specific practice specialty. This will include details like service provided, its type and practice location(s). (These can be multiple). The CAQH framework is intended to permit you to complete your profile over time, over multiple sessions if needed. You can stop any time, save what you have finished, and return later to complete the application process.

The privacy and security of healthcare service providers' and organizations' data and the protection of clients is a priority for CAQH. CAQH ProView is intended to be in compliance with government and state laws, rules and guidelines identifying with the security of individually recognizable healthcare data. Likewise, CAQH will conform to pertinent laws and guidelines relating to privacy and security in the development of the database and the complete data collection cycle.

What Is The CAQH Advantage? Especially In Medical Credentialing?

If you are a patient and you have tried finding a specialist or practitioner, you will doubtlessly be interested in the practitioners’ performance or practice history.

But an even bigger concern is if said practitioner is listed in the plan of your insurance provider.  If not, your insurance as a rule will not cover as much as it could have had you chosen a practitioner approved by the insurance agency. In other words, you have to pay a higher amount in co-insurance as well as in co-pay amount.

For patients, therefore, CAQH provides helpful data on how to locate the best medical professional for their needs.

Now let’s consider the healthcare provider’s point of view: Healthcare service providers need to enlist with Medicare to treat Medicare patients. In much the same way, being listed with the insurance agencies in the CAQH network positions them to serve patients within a stated vicinity or who require specific healthcare services.

In other words, as a healthcare practitioner, not being associated with CAQH will mean you’re missing out on key opportunities to increase your practice and drive clinic traffic.

CAQH Provider Medical Credentialing

Most healthcare service providers wish applications would be a one-size-fit-all with all insurance agencies. They would just need to fill and submit the information through the application process once. This is exactly what the CAQH medical credentialing advantage is. What CAQH is (The Council for Affordable Quality Healthcare, Inc.) basically a not for profit organization of medical coverage plans and healthcare affiliations devoted to improving healthcare practices and organizations. CAQH was set up to smoothen out the desk work needed for healthcare service providers and their representatives. CAQH Universal Provider Datasource (UPD) is a service which helps provide access to basic data needed to complete medical credentialing for healthcare providers. It works as a clearinghouse for insurance providers and is also free for healthcare service providers and practitioners. This is what CAQH does to make things efficient: The practitioners' data is entered into the CAQH credentialing database and can be accessible to all the insurance agencies using the database.

While a few insurers still have their own application process through which they verify practitioners, most insurance providers participate in the CAQH medical credentialing process. It’s certainly an industry need: Considering the trouble and time it saves. CAQH streamlines the whole process and permits the insurance agency to analyze the healthcare service providers' existing qualifications on CAQH without requiring a separate lengthy application procedure.

CAQH medical credentialing eliminates the repetitive tasks healthcare practitioners must engage in with every insurance agency. It is free and can be completed online. Some insurance agencies may require additional data.

Because of the complexity of the data that defines what CAQH is, applying for credentialing can be overwhelming and confusing for new doctors. There are experts who specialize in CAQH medical credentialing and can help a healthcare service provider. If you have not done this before in your practice or find the whole process overwhelming, you may outsource the process of medical credentialing to a trusted source (like Precision Hub). This will help you avoid mistakes and prevent delays in your revenue/collections cycle.

Since a healthcare practitioner's data may change, with new certifications or changes within the practice, CAQH sends periodic reminders to providers to verify the currency of their data. Doctors may verify their data online or through their registered contact number.  Regular updates help the system incorporate the latest developments in a practitioner's medical record. Many healthcare plans that the healthcare service provider is associated with utilize what the CAQH medical credentialing suggests: A database to refresh the practitioner's records.

Requirements: For healthcare practitioners who plan to participate in the CAQH healthcare credentialing process, their UPD database must have a legally binding contract with an insurance plan to benefit from what CAQH has to offer.

Why is the simplification of administrative tasks for medical credentialing an important topic to address?

Simplification of the administrative processes behind the medical credentialing cycle helps healthcare service providers increase their compliance with the prerequisite conditions set by industry or regulatory bodies. The desk work within credentialing is tedious for doctors, other healthcare providers, practitioners, and healthcare associations. A normal healthcare service provider signs contracts with 10 - 20 healthcare associations, each requiring the practitioner to finish a detailed medical credentialing application.

Many healthcare providers begin their credentialing cycle with an insurance agency before completing their CAQH profile. Odds are, the organization you need to get registered with already uses CAQH. It’s better to confirm this by checking the list of associations on the CAQH site first.  If it does, you will get a letter with your CAQH ID number. In case you do not get it immediately, call the insurance agency after fourteen days to ensure they received your medical credentialing application and can give you your CAQH ID number. Then again, you can self-register with CAQH before starting the medical credentialing process with any insurance agency. CAQH will send you an invite email with your allocated CAQH number. When you get the CAQH number, make sure you keep it safe: You'll need the CAQH number to complete your profile now and re-validate the data later.


As a healthcare provider, you may have ‘burnt your fingers’ during the credentialing process. At Precision Hub, we have experts who are constantly exploring new ways of making every front office and back office task quicker, safer and more rewarding for you, including medical credentialing.