Healthcare Credentialing Glossary
Definitions for common healthcare credentialing, provider enrollment, and payer terms.
Council for Affordable Quality Healthcare. CAQH ProView is the centralized database used by 1,000+ health plans to collect and verify provider credentials.
Provider Enrollment, Chain, and Ownership System. The CMS online system used for Medicare provider enrollment applications.
National Provider Identifier. A unique 10-digit number assigned to healthcare providers. Type 1 for individuals, Type 2 for organizations.
Provider Transaction Access Number. The unique Medicare ID issued by CMS after enrollment approval, required for Medicare billing.
The process by which insurance payers and facilities verify a provider's qualifications, licensure, and background.
The process of registering with insurance payers to participate in their network and bill for covered services.
The process by which a healthcare facility grants specific clinical rights to a provider based on verified credentials.
The periodic process by which CMS re-verifies enrolled Medicare and Medicaid providers, typically every 3 to 5 years.
The periodic re-verification process commercial payers conduct, typically every 2 to 3 years, to confirm providers remain qualified.
Tax Identification Number. Used for group-level insurance enrollment and billing. Also referred to as EIN (Employer Identification Number).
Medicare Administrative Contractor. One of 12 regional contractors that process Medicare enrollment applications and claims on behalf of CMS.
Managed Care Organization. A private insurance company that contracts with states to administer Medicaid managed care plans.
Electronic Funds Transfer. Direct bank deposit of insurance claim payments, replacing paper checks.
Electronic Remittance Advice. The electronic version of an Explanation of Benefits (EOB) sent with claim payments.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. A category of Medicare billing requiring separate CMS supplier enrollment.
Federally Qualified Health Center. A community-based healthcare provider that receives enhanced Medicare and Medicaid reimbursement.
Rural Health Clinic. A provider type certified under Medicare that offers enhanced reimbursement for services in rural areas.