Provider Data Validation During the Credentialing Process

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Provider Data Validation During the Credentialing Process


Date Issued: 4/16/2018

New York State and Federal regulations require EmblemHealth to maintain the accuracy of its provider file data, to ensure its Provider Directories meet basic information requirements and accuracy.

Through the initial credentialing and periodic recredentialing processes, EmblemHealth validates the accuracy of a provider’s service location data by reviewing against the provider’s data in CAQH ProView™ and performing telephone outreach.

CAQH ProView, formerly the Universal Credentialing Datasource®, was founded in 2002 to address the biggest challenge with provider credentialing. Data collection had been the most inefficient step of the credentialing process, placing unnecessary burden on providers. Previously, providers completed separate credentialing forms for each payer.

EmblemHealth’s data validation process leverages the data in CAQH ProView as the “source of truth” for service location data. Only service locations listed on CAQH Proview are eligible for validation, enrollment at initial credentialing or continued participation at recredentialing. Service locations not listed in CAQH ProView will be subject to validation by phone call and possible termination if unreachable or non-responsive.

To avoid a failed validation, denial of enrollment or possible break in service, please ensure your CAQH profile is up to date with all service addresses and telephone numbers where you take appointments.