ABSTRACT
This chapter provides readers with an overview of credentialing requirements and the credentialing process, including delegation of some or all of the credentialing activities. Managed-care organizations consist of three primary areas: Health Maintenance Organization (HMO), Physician Hospital Organization, and Preferred Provider Organization. Additional categories of contracted services within the managed-care environment include Independent Practice Association, Management Services Organization, and Accountable Care Organization. Designing, implementing, and maintaining strong credentialing practices also ensures that participating members in specific health plans are provided care by only the most qualified and competent practitioners. In 1991, the National Committee for Quality Assurance released its very first credentialing standards for HMOs. This action prompted many organizations throughout the country to examine their existing credentialing processes to determine what changes were needed to meet the stringent standards. Each provider organization is responsible for establishing criteria for participation within the organization, based on the needs of the members, clients, and the standards of the contracting entities.
