What is credentialing?
Credentialing is a systematic approach to the collection and verification of a provider's professional qualifications. These qualifications include, but are not limited to:
- Relevant training
- Licensure
- Certification and/or registration to practice in a health care field
- Academic background
Additionally, we assess whether each provider meets certain criteria relating to professional competence and conduct. The Aetna credentialing process is done before a provider joins the Aetna network. However, credentialing and network contracting are separate processes.
Aetna's Credentialing Verification Organization (CVO) meets the National Committee for Quality Assurance standards for health plans. In addition, Aetna’s CVO maintains accreditation by URAC by meeting strict quality standards.
How do I apply to join an Aetna network?
Here’s how to request to join a network:
- Individual medical providers: Medical Plans Application Request form
- Dental providers (excluding oral/maxillofacial surgeons): Dental Application Request form
- Behavioral health providers: Behavioral Health Application Request form
Aetna evaluates each provider's request for participation against the current need to service our membership in a specific geographic area.
I've heard of an organization called the Council for Affordable Quality Healthcare or CAQH. Can you tell me more about this organization?
CAQH is a nonprofit alliance of America’s leading health plans.
CAQH ProView allows providers to submit one application to meet the needs of all of the health plans and hospitals participating in the CAQH effort. To maintain the accuracy of the data, CAQH sends providers a reminder every 90 days to re-attest to their information.
Health plans and hospitals designated by providers obtain application information directly from the CAQH database. This eliminates the need for multiple organizations to contact the provider for the same information. CAQH gathers and stores detailed data for more than 1 million providers nationwide. Aetna uses CAQH ProView for credentialing all provider types.
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 that you have granted Aetna authorization to review your information.
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 after submitting your online Aetna application request form.
Complete the online CAQH application and grant Aetna authorization to review your information. Once you submit the online CAQH application, we obtain your data electronically and begin 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?
Medversant ProviderSource is a free service used to collect practitioner credentialing data in the state of Washington, similar to CAQH ProView.
Does Aetna use ProviderSource?
Yes. Aetna uses ProviderSource for successfully registered, directly credentialed practitioners in Washington State. When practitioners complete their online application in ProviderSource, they must designate Aetna as an authorized heath plan.
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 online application request form?
Once Aetna receives your completed application, your information will be evaluated against our business requirements, and your credentials will be validated. Once this process is complete, you will receive written notification that your credentialing is complete.
Credentialing and contracting are separate and distinct processes. Once the contracting process is complete, your network management contact will notify you.
If you have questions about your participation, please call the appropriate Aetna network area:
- Aetna HMO-based and Medicare Advantage plans: 1-800-624-0756
- All other plans: 1-888-MD-Aetna (1-888-632-3862)
- Aetna Behavioral Health: 1-888-632-3862
- Aetna Better Health IL, LA, NE, NJ, NY, OH, PA and TX: Go to http://www.aetnabetterhealth.com/Default.aspx and select the appropriate state to obtain contact information
- Aetna Workers’ Comp Access® 1-800-238-6206
- Cofinity®: 1-800-831-1166
- Coventry/First Health: 1-800-937-6824
Will I be notified if errors are discovered during the credentialing process?
Yes, we will notify you of any information errors. It is your responsibility to work directly with the reporting entity (or entities) to correct the information.
How can I check on the status of my (re)credentialing application?
Our Credentialing Customer Service department is happy to assist you. Please contact us:
- Medical and Behavioral Health: 1-800-353-1232
- Dental: 1-800-451-7715
