What is credentialing?
Credentialing is a systematic approach to the collection and verification of a provider's professional qualifications. The qualifications that are reviewed and verified include, but are not limited to, relevant training, licensure, certification and/or registration to practice in a health care field, and academic background. Additionally, Aetna conducts an assessment of whether the provider meets certain criteria relating to professional competence and conduct. The Aetna credentialing process evaluates the qualifications of providers prior to inclusion in the Aetna network. However, credentialing and network contracting are separate processes.
Aetna's Credentialing Verification Organization (CVO) meets the National Committee for Quality Assurance (NCQA) standards for health plans. In addition, Aetna’s CVO maintains accreditation by URAC by meeting strict quality standards.
Interested in applying for participation in an Aetna Network?
Aetna evaluates each provider's request for participation with Aetna health plans against the current need to service the membership in a specific geographic area. Providers can complete a request for participation online at http://www.aetna.com/about-aetna-insurance/contact-us/forms/doctors_hospitals/index.html or by calling one of the following numbers:
I've heard of an organization called the Council for Affordable Quality Healthcare or CAQH. Can you tell me more about this organization?
Many health plans...one solution! The Universal Provider Datasource was developed by America’s leading health plans collaborating through the Council for Affordable Quality Healthcare, or CAQH. The Universal Provider Datasource is the leading, industry-wide service to address one of providers’ most redundant administrative tasks: the credentialing application process.
Under the CAQH program, providers use a standard application and a common database to submit one application to one source to meet the needs of all of the health plans and hospitals participating in the CAQH effort. To maintain the accuracy of the provider’s data, CAQH sends a reminder every 90 days for providers to re-attest to their information.
Health plans and hospitals designated by providers obtain the application information directly from the database, eliminating the need to have multiple organizations contacting the provider for the same standard information. Providers update their information quarterly to ensure data is current and accurate. CAQH gathers and stores detailed data from more than 960,000 providers nationwide. Aetna uses the CAQH Universal Provider Datasource for our credentialing needs for all provider types.
Want to learn more about the CAQH Universal Credentialing Datasource? Visit the CAQH website.
If I am already registered with CAQH, what are my next steps?
If you have already registered with CAQH or have received registration information from CAQH, no further correspondence will be sent to you. Please ensure you have granted "Aetna" authorization to review your information. As a reminder:
Call 1-800-353-1232 to request participation.
If I have not yet registered with CAQH, what are my next steps?
If you have not completed CAQH’s online registration, you will receive a registration kit from CAQH within 7–10 business days. Once you receive your registration kit, complete the CAQH application and grant "Aetna" authorization to review your information.
Once you complete the CAQH application, Aetna obtains your application data electronically and begins the credentialing process.
I've heard of a new electronic credentialing service being offered to Washington State licensed health care practitioners in accordance with Senate Bill 5346. Can you tell me more about this?
Senate Bill 5346 introduces a centralized data collection organization – Medversant ProviderSource (ProviderSource). It is a free service used to collect practitioner credentialing data, similar to CAQH’s Universal Datasource.
Has Aetna begun using ProviderSource?
Yes. Aetna has begun using ProviderSource for successfully registered, directly credentialed practitioners in Washington State. We encourage practitioners to use ProviderSource as soon as possible to make credentialing through this new service easier. When practitioners complete their online application in ProviderSource, they must designate Aetna as an authorized heath plan. As a reminder:
Call 1-800-353-1232 to request participation.
To register, or if you have questions about ProviderSource, visit the ProviderSource website
What happens next? Can I begin seeing Aetna members once I submit my application for participation?
Once Aetna receives your completed application for participation, your information will be evaluated against our business requirements, and your credentials will be validated as described in the "What is credentialing?" question above. Once this process is complete, you will receive written notification that your credentialing is complete. The credentialing and contracting processes are separate; your Aetna network manager will contact you about your participation status.
If you have questions about your participation, please call the appropriate Aetna network area:
Will I be notified if erroneous information is discovered during the credentialing process?
Yes, the Aetna Credentialing department will notify you if erroneous information is discovered during the verification process from any primary source. It is your responsibility to work directly with the reporting entity(ies) to correct the erroneous information.
How can I check on the status of my (re)-credentialing application?
Aetna has a Credentialing Customer Service department that is happy to assist you if you have any questions about your credentialing or recredentialing process. You can call Credentialing Customer Service for medical providers at 1-800-353-1232. For behavioral health providers, please call 1-800-999-5698.