Credentialing is the process of obtaining and reviewing documentation to determine participation status in a health plan. The documentation may include, but is not limited to, the applicant’s education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history and professional competence. Generally, the terms credentialing and recredentialing include the review of the information and documentation collected, as well as verification that the information is accurate and complete.

Please note:

• Facilities and organizational providers that are already contracted with Humana but need to be recredentialed should download our organizational provider recertification form application and return it by fax to 1-502-508-0521.
• Puerto Rico healthcare professionals interested in credentialing should send an email to PRCredentials@humana.com or call 1-877-384-5037. The information below does not apply to Puerto Rico.
• The current credentialing and recredentialing policies can be viewed here .
• To inquire about a credentialing status, please call 1-800-626-2741.

Credentialing process

Humana requires the use of Council for Affordable Quality Healthcare (CAQH) ProViewTM, a service that provides a fast and easy way to securely submit credentialing information to multiple plans and networks by entering information just once. Application data can be submitted online at any time. This simplified credentialing process reduces paperwork and saves time. It is provided at no cost.

Arkansas physicians and other healthcare professionals are not required to use Council for CAQH ProView and should contact their state medical board to determine its required credentialing procedures.

To become credentialed for the first time, you will need a current and complete CAQH ProView application. Please be sure to:

• Complete all fields on the form or mark them N/A.
• Include all prior and current practice locations.
• Include identification numbers, such as the physician or provider’s Social Security number, National Provider Identifier (NPI), Drug Enforcement Agency number, unique provider ID and professional license numbers.
• Answer all questions and provide explanations if needed.
• Include the signed and dated attestation form.
• Provide digital copies of your:
  
  • Curriculum vitae, including work history in a month/year format
  • Professional license
  • DEA certificate (if applicable)
  • Controlled Dangerous Substances (CDS) certificate (if applicable)
  • Copy of malpractice insurance face sheet
  • Summary of pending or settled malpractice cases

Please be sure to grant Humana access to the CAQH ProView application.

Important credentialing update for WI, CO, and MA

Humana is entering into a multi-payer credentialing solution in partnership with Elevance and Sutherland Healthcare Solutions. This initiative aims to streamline the recredentialing process, enhance efficiency and reduce administrative burdens for our providers.

Pilot regions: This program will initially launch as a pilot in Wisconsin, Colorado and Massachusetts.

Action required: Please ensure your CAQH profiles are up-to-date and authorized for information sharing across plans. Your earliest recredentialing date will determine the start of this consolidated process. Once your recredentialing is complete, your file will be shared with all affiliated health plans, standardizing your recredentialing date across these organizations.

Getting started

Physicians and other healthcare professionals obtain their CAQH provider ID directly from CAQH by going to  CAQH website  and completing a registration form. Once the form is submitted, the applicant will receive an email from CAQH with a CAQH provider ID. Then the applicant will be able to sign in to CAQH ProView and create a username and password, which are used to complete the online application.

The process incorporates the standard application data set and, where appropriate, accounts for additional credentialing information required by states with specific application mandates. Before the completed application is available to a participating organization or health plan, the applicant must authorize release of the data. Each organization that has included the applicant on its roster will appear on the authorization screen for the healthcare professional to review and authorize.

The applications are stored in an online database and are always available to the applicant to review or print.

Once a physician or other healthcare professional completes the process, automatic reminders are sent each quarter to prompt a review and update of the information.

After you receive your CAQH ID, visit our  contracting webpage  to begin a contract application.

For more information about CAQH, please  visit CAQH’s website  and select “CAQH ProView®.”

If you cannot participate with CAQH ProView, please contact your local market representative.