What is CAQH Credentialing? A Complete Guide for Health Plans and Payers

Credentialing is one of the most important—and resource-intensive—administrative functions for payers. Before a healthcare provider can join a network, insurers must verify their qualifications, licenses, training, work history, and other relevant credentials. Done manually, this process can be slow, costly, and prone to errors, adding to an already daunting and messy provider data maintenance process.

That’s where CAQH credentialing comes in. By standardizing and centralizing provider credentialing data, CAQH helps payers simplify the credentialing process, reduce administrative burden, and improve accuracy across networks.

There’s been a misconception that CertifyOS is a credentialing platform just like CAQH. This is untrue, as we are not competitors and instead, work hand-in-hand to help payers with provider data management. Credentialing was our entry point (by design), but credentialing is just the start of what CertifyOS does. By starting there, we’ve been able to work with data sources like CAQH to create the infrastructure for a continuously maintained, enterprise-wide engine that powers provider data management.

In this guide, we’ll explain what CAQH credentialing is, how CertifyOS interacts with CAQH data, why it matters for payers, and how insurers can leverage it to strengthen operations and deliver a better provider and member experience.

What is CAQH?

The Council for Affordable Quality Healthcare (CAQH) is a nonprofit alliance of health plans and trade associations focused on streamlining healthcare administration. Its flagship solution, CAQH ProView, is the most widely used provider data portal in the U.S.

More than 2 million healthcare providers maintain their credentialing profiles in CAQH, and most major health plans rely on the platform to access credentialing data.

CertifyOS’s system continuously updates data from thousands of primary sources (including CAQH), making provider data, including credentialing information, accessible via a single API.

What is CAQH Credentialing?

CAQH credentialing refers to the process by which payers use CAQH ProView to obtain and verify their credentials, enabling them to participate in networks.

Instead of requiring providers to submit duplicative paper applications, insurers can access a single, standardized source of truth. Providers update their CAQH profile with demographic, education, licensure, and malpractice information, and payers pull that data directly into their credentialing workflows.

CertifyOS’s platform utilizes this CAQH data to establish a comprehensive “central nervous system” of data for payers. Our clients are seeing the impact of reduced administrative costs, quicker provider onboarding times, and real-time updates to ensure their data is always up-to-date.

Why CAQH Credentialing Matters for Payers

For payers, provider data isn’t just a regulatory requirement; it’s central to building trusted networks and ensuring members receive safe, high-quality care. Leveraging CAQH data to ensure that all provider credentials are up-to-date delivers benefits across several dimensions:

1. Operational Efficiency: Having credentialing data in one place eliminates paper-based submissions and redundant processes. This streamlines data collection from providers, and cuts administrative costs and time spent chasing incomplete files
2. Data Accuracy: Provider data is updated directly by clinicians and attested to every 120 days; CertifyOS’s platform combs primary sources to ensure that updates are made in real time. This reduces the risk of outdated or inconsistent provider information and improves accuracy across directories and claims systems
3. Compliance: Ensures credentialing meets NCQA, URAC (Utilization Review Accreditation Commission), CMS (Centers for Medicare and Medicaid Services), and state requirements, simplifying audits by maintaining centralized, verified data.
4. Provider Experience: Reduces frustration and confusion for patients seeking in-network care. By streamlining the provision of data, you can minimize the administrative burden on providers, expedite the time-to-network participation and reimbursement process, and strengthen payer-provider relationships.
5. Member Experience: More accurate provider directories for members searching for care, and ensure that your networks include qualified, vetted providers.

How Does CAQH Credentialing Work for Payers?

The CAQH credentialing process involves coordination between providers and payers. Here’s what it looks like from the insurer’s perspective:

1. Provider Enrollment Providers complete a CAQH ProView profile, including demographic information, licensure, work history, and insurance details.
2. Data AccessPatients request access to the provider’s profile. Once authorized, they can view and download all relevant data.
3. Primary Source Verification (PSV)Payers still must verify provider credentials (such as state licenses, board certifications, and malpractice history) through primary sources. CAQH centralizes the data, making verification faster.
4. Ongoing Maintenance Providers must attest every 120 days that their information is accurate and up-to-date. Payers can rely on this attestation for compliance and ensure their directories remain up-to-date.
5. RecredentialingEvery 2–3 years, payers recredential providers. CAQH simplifies this by allowing payers to re-access updated profiles rather than requiring a new paper submission.

Common Challenges in Credentialing

Insurers that don’t fully leverage platforms like CertifyOS to ensure up-to-date data often face persistent challenges.

• Manual processing slows down onboarding and creates backlogs.
• Incomplete or inconsistent provider data leads to compliance risks and directory inaccuracies.
• Provider frustration with duplicative paperwork can strain relationships and delay participation.
• Higher administrative costs due to repeated requests for the same information.

In contrast, CertifyOS’s platform, coupled with CAQH’s data, offers a single, standardized hub that mitigates these issues.

How Long Does CAQH Credentialing Take?

While CAQH streamlines the process, the overall credentialing timeline still depends on:

• Provider responsiveness in completing profiles
• Document submission and attestation
• Payer verification processes

Most credentialing cycles take 30–90 days, but CAQH can significantly reduce delays by ensuring data is available and standardized upfront.

Innovation to Support Credentialing

CAQH and CertifyOS play complementary roles in the credentialing process. CertifyOS’s integrations enable auto-rostering on CAQH, helping health plans to avoid burdensome manual processes. CertifyOS’s real-time, API-enabled updates give administrators confidence that their data is up-to-date.

Tools like CertifyOS are building the infrastructure to power a single source of truth for provider data, including integrations with data from sources like CAQH. We aim to further automate compliance, reduce manual work, and enhance provider data accuracy across the healthcare system.

For payers, this means less time chasing paperwork and more time focusing on network strategy, provider partnerships, and member outcomes. By centralizing provider data, simplifying credentialing, and improving accuracy, CertifyOS and CAQH help insurers:

• Reduce costs
• Speed up provider onboarding
• Strengthen compliance
• Improve provider and member experience

In today’s healthcare landscape, where accurate provider data and efficient processes are crucial, high-tech solutions like CertifyOS are the standard for payers seeking to build robust networks and deliver value to their members. Discover how our platform leverages CAQH data to minimize errors and expedite onboarding.