Credentialing Process

The credentialing process varies depending on whether an individual practitioner or an organization is being credentialed.

Organizations

For Organizations, credentialing must be completed every three (3) years. Read more

Providers

Providers must complete a CAQH profile and be contracted before credentialing. Read more

Practitioner Credentialing

Practitioners must complete the practitioner contract application and approval process prior to credentialing with University of Utah Health Plans. Once credentialed, providers may begin to see members.

Initial credentialing and subsequent re-credentialing every three (3) years is required for all physicians and other types of health care professionals practicing under their own license as permitted by state law with whom members schedule appointments. The credentialing program follows the standards set forth by the National Committee for Quality Assurance (NCQA) and uses CAQH exclusively for the credentialing application.

University of Utah Health Plans requires that Advanced Practice Professionals (APP), including PAs, complete credentialing.

Where to Start? Let’s Get Started!

For new practitioners with your practice, simply send the following information for each practitioner to be credentialed, or a roster containing the information below, to our credentialing team at provider.credentialing@hsc.utah.edu.

  • Practitioner’s first and last names with middle initial
  • Practitioner’s title
  • Practitioner’s specialty
  • Practitioner’s date of birth
  • Practitioner’s CAQH Provider ID
  • Provider NPI
  • Group Tax ID
  • Primary practice location
  • Credentialing contact name and email address

Do you have a CAQH ID?

  • Practitioner with CAQH ID

    Steps to Follow:

    1. Ensure University of Utah Health Plans has been granted permission to access your application
    2. Review, update and re-attest to application's correctness and completeness

  • Practitioner without CAQH ID

    Steps to Follow:

    1. Complete a CAQH application
    2. Ensure University of Utah Health Plans has been granted access to application

Organizational Practitioner Credentialing

Credentialing is completed upon initial contracting and then every three (3) years in accordance with our Credentialing Policy.

University of Utah Health Plans ensures that all organizational practitioners have the following:

  1. Current state license(s) and/or certification in good standing with state and federal authorities
  2. Adequate liability coverage
  3. Site visits maybe required at the discretion of the credentials committee
  4. Birthing centers must have a clear, written plan of transfer and transition of care in emergency circumstances. The plan must include the name(s) of the Hospital and the OB/GYN practitioner(s) providing backup.

To download the Organizational Practitioner Credentialing Application, please click on the link below.
Organizational Practitioner Credentialing Application

Credentialing Review

Initial and Reappointment Decisions

The decision to accept or reject a practitioner’s application for initial or reappointment is based on information generated through primary source verifications including but not limited to:

  1. Application information
  2. Complaints and grievances
  3. Malpractice history
  4. Licensure in good standing
  5. Education/training or board certification in the practice specialty

Other sources of information may be considered as appropriate and relevant at the sole discretion of the Credentialing Committee members.

Ongoing Monitoring

University of Utah Health Plans does ongoing monitoring of practitioner sanctions and disciplinary actions. Reports from the following are reviewed monthly:

  1. National Practitioner Databank (NPDB)
  2. Office of Inspector General (OIG)
  3. System for Award Management (SAM)
  4. Departments of Professional Licensing

Practitioners with Medicare / Medicaid sanctions, or who have a business relationship with another practitioner or entity that has been debarred or excluded, will be terminated from the University of Utah Health Plan's participating networks. Practitioners who have had restrictions placed upon their license to practice will be presented to the Credentialing Committee for a decision on the appropriate action to be taken.

For any unfavorable decisions, practitioners may consult the Practitioner Appeal Rights in the Credentialing Policy.

Practitioner Rights

The applicant shall have the right to be informed of their application status (Ready for Committee, App In-process, App Incomplete or Missing Information) upon request. The request shall be made via email to: provider.credentialing@hsc.utah.edu, or by phone to 801-587-2838, opt 3. Information on Practitioner Rights may also be found in the Provider Manual. Emails will be responded to within 24 hours, and voice mails returned within 48 hours.

The Practitioner will have the opportunity to correct any erroneous information, as applicable, during the 2-3 month credentialing process. Applicants are notified of this right through our Provider Manual and details of the process are outlined in our Credentialing Policy.

Upon request, applicants may review the information s/he has submitted in support of their credentialing or re-credentialing application and if something requires correction, practitioners will be asked to amend their CAQH application.

University of Utah Health Plans is not required to reveal sources of information that are part of our verification requirements or if federal or state law prohibits us, such as NPDB reports. The applicant may view their file in the presence of the University of Utah Health Plans Medical Director and a member of the credentialing team. Applicants are notified of these rights in the Provider Manual and Credentialing Policy..

Practitioner Rights

Questions about Plans?