Verify education and training for health plan credentialing

Practitioners undergo different levels of education and training, including medical or professional school, and internship, residency, and fellowship programs. The health plan is only required to verify the highest level that the applicant completed. For a physician, this would usually be the residency training program. For a nurse practitioner, this may be the accredited master’s level program. Please note that verification of a fellowship does not meet the intent of this standard, as not all fellowships follow a standard practice of verifying residency as part of its application process. While health plans must verify residency for non-board certified physicians, many will also verify fellowship training if the applicant completed this type of training program especially if the practitioner will be listed under the fellowship specialty in the member directory. Also note that for physicians who are board certified, which is considered the highest level of training, there are circumstances where verification of residency training may still be required.

To verify education or training, health plans may access the various sources available based on the applicant’s area of practice. In addition to contacting the school or training program directly, typical sources include the AMA/AOA profile, the Education Commission for Foreign Medical Graduates (ECFMG), and the National Student Clearinghouse. For physicians, please note that NCQA only recognizes residency training programs that are recognized by one of the following entities: Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), the College of Family Physicians of Canada (CFPC), or the Royal College of Physicians and Surgeons of Canada (RCPSC). If an applicant has completed a residency program that is not recognized by NCQA, then the medical school must be verified.

Source: Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities