Delegated Credentialing

When a healthcare organization works with many providers, keeping up with credentialing can be time-consuming. To save time and reduce administrative work, many health plans allow trusted organizations like hospitals or large medical groups to handle credentialing on their behalf. This setup is called delegated credentialing. It lets provider groups manage the process internally, following the rules set by the health plan.

This approach speeds up onboarding and improves control over how providers are added to networks. But to do it right, there are specific rules and agreements that must be followed. 

In this blog, let’s explore what delegated credentialing is, how the delegated credentialing process works, the benefits, requirements, and how Atlas Systems supports organizations with efficient, compliant solutions.

What is Delegated Credentialing in Healthcare?

Delegated credentialing is when a health plan or insurance company gives a trusted healthcare organization the responsibility to credential its own providers. Instead of the health plan checking each provider’s qualifications directly, it allows the provider group, like a hospital, clinic, or medical group, to follow approved guidelines and manage the process internally.

This is done through a formal agreement, often based on a: 

• Delegated credentialing policy and procedures document 
• Delegated credentialing agreement template

These outline what needs to be done, how often, and who is responsible. The organization must meet certain standards and pass regular audits to maintain this privilege. When done correctly, delegated provider credentialing helps speed up onboarding and ensures that qualified professionals can start seeing patients sooner.

The range of information needed to make credentialing decisions typically includes:

• Valid state licenses
• Registration for prescribing controlled substances (DEA registration)
• Certification to handle controlled drugs (CDS certification)
• Board certifications or specialty qualifications
• Education and training background
• History of malpractice claims or lawsuits
• Records of any professional liability settlements
• Previous work experience
• Affiliations with hospitals or medical facilities
• Answers to disclosure questions about legal or ethical issues
• Signed statements confirming the accuracy of information (attestations)
• Records of any sanctions or exclusions from practice

Ongoing Credentialing Obligations

Getting approved for delegated credentialing is just the beginning. Once the organization takes over the process, it must follow strict rules to keep that responsibility. This includes: 

• Regularly verifying provider qualifications
• Maintaining up-to-date records
• Completing re-credentialing within the required timelines

There are also regular audits to check if the organization is following the delegated credentialing policy and procedures correctly. Any mistakes or missed steps can lead to serious issues, including the health plan taking back control of the process. Staying compliant is key to keeping the benefits of delegated provider credentialing in place.

Understanding Regulators and Delegated Credentialing

In healthcare, regulators are organizations that set the rules and standards to make sure care is safe, providers are qualified, and systems work properly. They help ensure that credentialing is done fairly, consistently, and with the patient’s best interest in mind.

Regulators like the National Committee for Quality Assurance (NCQA), Centers for Medicare & Medicaid Services (CMS), and local state government agencies play a huge role in how the delegated credentialing process works. 

NCQA is a private organization that sets quality and accreditation standards many health plans follow. CMS is a federal agency that oversees Medicare and Medicaid, requiring health plans to meet strict credentialing rules even when they delegate this task. Meanwhile, local state governments issue licenses and enforce rules to protect patients at the state level.

Even when a health plan allows a provider group to manage its own credentialing, it must make sure the group follows these regulatory guidelines. The health plan is still responsible for the final outcome.

To meet these expectations, organizations must: 

• Create detailed policies
• Use approved delegated credentialing agreement templates
• Ensure their internal process meets regulatory requirements

Regular reviews and audits help keep everything in line. Knowing what these regulators expect is needed for running a smooth and compliant delegated credentialing process.

Delegated Credentialing: An Increasingly Important Strategy

As healthcare organizations grow and manage larger provider networks, the need for faster, more efficient credentialing has become critical. Traditional credentialing methods can be slow and repetitive. This is where delegated credentialing stands out, it offers a way to reduce delays and speed up provider onboarding.

With accelerated delegated credentialing, approved organizations can bring providers into their network faster, helping meet patient needs without waiting weeks or months for approval. It also gives provider groups more control over their own processes, making it easier to maintain quality and accuracy. For many healthcare systems, it’s no longer just an option, it’s a smart, long-term strategy to keep up with demand and ensure timely access to care.

Benefits of Delegated Credentialing

Delegated credentialing offers more than just faster paperwork. It helps healthcare organizations improve efficiency, reduce costs, and deliver better service to both providers and patients. When done right, it becomes a valuable part of an organization’s long-term growth and quality strategy.

Here are 5 benefits of delegated credentialing:

• Reduces the time it takes to onboard new providers by handling credentialing in-house. Instead of waiting weeks for a health plan to process paperwork, provider groups can quickly verify qualifications and get providers seeing patients sooner. 
• Supports compliance with regulatory and payer standards through structured procedures. Following approved policies and regular audits helps organizations avoid penalties and maintain trust.
• Cuts down administrative workload for both the health plan and the provider group. By sharing responsibility, each side avoids duplicate work, freeing staff to focus on other priorities.
• Improves provider satisfaction by speeding up approval and start dates. When providers join faster, they feel valued and ready to contribute without unnecessary waiting. 
• Allows better control over the credentialing process and provider data management. Organizations can maintain up-to-date records, spot errors faster, and update credentials as needed without waiting for outside approval.

Supporting Your Credentialing Journey With PRIME® by Atlas Systems

Delegated credentialing offers many benefits, but success depends on accuracy, consistency, and ongoing oversight. Managing policies, staying audit-ready, and ensuring compliance can be complex without the right tools and expertise.

PRIME® by Atlas Systems offers provider credentialing services that simplify this process. With automation, real-time tracking, and built-in compliance checks, we help healthcare organizations speed up onboarding, maintain data accuracy, and meet regulatory requirements efficiently. 

As part of our complete provider lifecycle management solution, PRIME® offers end-to-end support covering credentialing, re-credentialing, privileging, and ongoing provider data management. This comprehensive approach ensures your entire provider lifecycle is managed smoothly and compliantly, allowing your organization to focus on delivering quality patient care.

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FAQs

What is the difference between direct and delegated credentialing?

Direct credentialing is done by the health plan itself, checking provider qualifications, licenses, and background before approving them. Delegated credentialing lets an approved organization manage the credentialing process internally under the health plan’s oversight. This means the organization is responsible for verifying and keeping records, but the health plan still monitors to make sure everything is done correctly.

Can a delegate who gives up credentials be re-credentialed?

Yes. If a provider or delegate stops practicing or gives up their credentials, they can go through the credentialing or re-credentialing process again if they want to return or continue. The organization must follow the same procedures to ensure the provider meets all current requirements before allowing them back.

What is a delegated credentialing agreement?

It’s a formal document between the health plan and the healthcare organization. This agreement outlines the responsibilities, rules, and processes the organization must follow when managing delegated credentialing. It also defines how often reviews happen, what standards must be met, and how audits will be conducted to keep the process transparent and compliant.