The Credentialing & Payer Enrollment Dictionary
Authoritative definitions and operational significance for healthcare revenue cycle, compliance, and credentialing terminology.
CAQH ProView
The national online credentialing database used by over 1,000 health plans and hospitals to streamline data collection. Clinicians must re-attest their information every 120 days to maintain active standing.
Primary Source Verification
The direct verification of a healthcare practitioner's credentials (medical degree, residency, state license, DEA registration, board certification) directly with the issuing institution or registry.
PECOS (Provider Enrollment, Chain and Ownership System)
The electronic Medicare enrollment system operated by CMS where providers submit CMS-855 forms, reassign billing privileges, and track national provider enrollment.
National Plan and Provider Enumeration System
The administrative database that issues 10-digit National Provider Identifiers (NPI Type 1 for individuals, NPI Type 2 for group practices).
Delegated Credentialing
A contractual arrangement where a health plan permits a qualified healthcare organization or MSO to perform its own credentialing and submit roster files instead of individual payer applications.
National Practitioner Data Bank
A confidential federal information clearinghouse created to improve healthcare quality by identifying adverse actions, malpractice payments, and loss of license.
Retroactive Effective Date
The policy where a health plan permits claims for dates of service backdated to the original application submission date rather than the committee approval date.
Medicaid Managed Care Organization
Private insurance entities contracted with state Medicaid agencies to deliver healthcare services to enrolled beneficiaries.
Experience Painless Healthcare Credentialing
ClearPath Payer simplifies complex payer enrollment workflows for fast-growing medical groups.