What is Credentialing?

Credentialing is a systematic approach to collection and verification of a practitioner applicant's professional qualifications, such as relevant training, licensure, certification, and/or registration to practice in a healthcare field, and academic background, as well as an assessment of whether the practitioner meets certain criteria relating to professional competence and conduct. The Aetna credentialing process evaluates the qualifications of practitioners who provide care to Aetna members. This process is completed before a practitioner is accepted for participation in an Aetna network.

back to top

Interested in applying for participation in an Aetna Network?

Each provider's request for participation within Aetna’s Health Plans will be evaluated against the current need to service the membership in a specific geographical area. Requests for participation can be requested by contacting one of the following numbers:

• Individual Medical Provider: Complete the online Health Professionals - Medical Plans Application Request form or contact 1-800-353-1232
• Dental Providers (excluding oral/maxillofacial surgeons): 1-800-451-7715
• Behavioral Health Providers: Complete the online Health Professionals - Behavioral Health Application Request Form Medical Plans or contact 1-800-999-5698

back to top

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 Credentialing DataSource was developed by America’s leading health plans collaborating through the Council for Affordable Quality Healthcare, or CAQH. The Universal Credentialing DataSource is the leading industry-wide service to address one of providers’ most redundant administrative tasks: the credentialing application process.

Under the CAQH program, practitioners use a standard application and a common database to submit one application, to one source, and update it on a quarterly basis to meet the needs of all of the health plans and hospitals participating in the CAQH effort. Health Plans and hospitals designed by the practitioners will obtain the application information directly from the database, eliminating the need to have multiple organizations contacting the practitioner for the same standard information. Practitioners update their information on a quarterly basis to ensure data is maintained in a constant state of readiness. CAQH will gather and store detailed data from more than 600,000 practitioners nationwide.

Want to learn more about the CAQH Universal Credentialing Data Source? Visit the CAQH website listed below:

http://www.CAQH.org/

back to top

I want more information about Aetna's Participation with CAQH's online application.

• Aetna utilizes the CAQH Universal Credentialing DataSource for our credentialing needs for all provider types.
• Just fill out the Health Professionals – Medical Plans Application Request or if an Behavioral Health practitioner the Health Professionals - Behavioral Health Application Request Form and we will add you to our CAQH – Aetna Provider Roster if applicable.
• If you have already registered with CAQH or have received registration information, no further correspondence will be sent to you. Please ensure you have granted "Aetna" authorization to review your information.
• If you have not completed the online registration, you will receive a registration kit within 7 – 10 business days. Once you receive your registration kit, complete the CAQH application and be sure to grant "Aetna" authorization to review your information.
• Once you complete the CAQH application, Aetna obtains your application data electronically and begins the credentialing process.

For more information about the CAQH roll out schedule and participating Heath plans, please visit the CAQH online application site at https://caqh.geoaccess.com/oas/

back to top

If I have registered with CAQH, will Aetna accept this information in place of my Aetna application?

Yes. Just fill out the online Health Professionals – Medical Plans Application Request form or if an Behavioral Health practitioner the Health Professionals - Behavioral Health Application Request Form and we will retrieve your information from the Universal Credentialing Data Source. When populating this online data source with your information, please remember to provide Aetna with authorization to obtain your credentialing information from CAQH.

back to top

If I have not yet registered with CAQH, what are my next steps?

Simply fill out the Aetna application request form (see above) and we will enter your name in our New Provider Applicant Roster. A new provider registration package with your secure ID number arrives at your doorstep in 7-10 business days.

back to top

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 pursuant to Aetna business requirements and your credentials will be validated as described in "What is Credentialing" above. Once this process is complete, you will receive written notification as to your participation status with Aetna.

back to top

Will I be notified if erroneous information is discovered during the credentialing process?

Yes, the Aetna credentialing department will notify a provider's office if erroneous information is discovered during the verification process from any primary source. It is the responsibility of the provider to work directly with the reporting entity(ies) to correct the erroneous information.

back to top

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 regarding your credentialing or recredentialing process. You can contact Credentialing Customer Service at:

For Medical Providers: 1-800-353-1232
For Behavioral Health Providers: 1-800-999-5698
 

back to top