The healthcare credentialing industry is notorious for its alphabet soup of acronyms and jargon. Whether you're a new provider trying to understand what forms you just signed, an office manager taking on the credentialing burden, or someone looking to enter the medical administration field, this A-Z glossary covers the essential terms you need to know.
A
Attestation Concept
The process of officially swearing or confirming that the information provided (usually on a CAQH profile or application) is accurate, true, and complete. In CAQH, providers must attest their profile every 120 days for it to remain active.
C
CAQH (Council for Affordable Quality Healthcare) Organization
A non-profit alliance of health plans. They operate CAQH ProView, a universal credentialing database where providers enter their information once, and multiple insurance companies can pull that data for their credentialing processes.
CPCS (Certified Provider Credentialing Specialist) Certification
A professional certification offered by the National Association Medical Staff Services (NAMSS) that demonstrates high-level expertise in credentialing and primary source verification.
CVO (Credentials Verification Organization) Entity
An organization that specializes purely in gathering and verifying a provider's background, training, and qualifications on behalf of a hospital, group practice, or insurance plan. They perform Primary Source Verification (PSV).
D
Delegated Credentialing Process
An arrangement where a health plan trusts an external entity (like a large hospital system or large group practice) to perform its own credentialing. Instead of the payer checking the provider's background, the group does it and simply sends a roster of approved providers to the payer.
E
EFT / ERA (Electronic Funds Transfer / Electronic Remittance Advice) Billing
EFT is how insurance companies pay providers via direct deposit. ERA is the electronic explanation of exactly what that payment matches to. Proper credentialing ensures both are set up accurately.
I
In-Network / Out-of-Network Status
Being "in-network" or a "participating provider (PAR)" means you have been fully credentialed and have signed a contracted rate agreement with a payer. "Out-of-network" means no contract exists.
M
MAC (Medicare Administrative Contractor) Entity
Private health care insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims or Durable Medical Equipment (DME) claims. You apply for Medicare enrollment through your regional MAC.
N
NPDB (National Practitioner Data Bank) Database
A web-based repository of reports containing information on medical malpractice payments and certain adverse actions related to healthcare practitioners. Payers ALWAYS query the NPDB during credentialing.
NPI (National Provider Identifier) Identifier
A unique 10-digit identification number issued to healthcare providers in the United States by CMS. Type 1 is for individual practitioners. Type 2 is for organizational entities like clinics or incorporated group practices.
P
PECOS (Provider Enrollment, Chain, and Ownership System) System
The electronic Medicare enrollment system. Providers use PECOS to submit, review, and update their Medicare enrollment information online instead of using paper 855 forms.
PSV (Primary Source Verification) Concept
The process of verifying a provider's credentials (like their medical degree, board certification, and state license) directly from the organization that issued them, rather than accepting a copy from the provider.
R
Revalidation / Re-Credentialing Process
Payers require providers to prove they are still qualified to practice every 2–3 years (Medicare calls it Revalidation; commercial payers call it Re-Credentialing). Missing these hard deadlines leads to immediate contract termination.
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