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Free Caqh Provider Application PDF Template

The CAQH Provider Application Form is a standardized tool utilized by healthcare providers to submit their information to insurance networks, making the credentialing process streamlined. Designed to eliminate the need for multiple applications across different insurance companies, this form ensures that providers' details like personal information, professional IDs, and educational background are formatted correctly and consistently. By following the detailed instructions and tips provided, healthcare professionals can avoid common processing delays, ensuring their application is handled efficiently.

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Free Caqh Provider Application PDF Template

Outline

Navigating the landscape of medical credentials becomes significantly easier with the introduction of the CAQH Provider Application form, a comprehensive document designed to streamline the often complex and time-consuming process of credentialing for healthcare professionals. This form, meticulously detailed, obliges the provider to furnish information in areas ranging from personal identification and professional IDs to educational background and specialty certification, ensuring a robust profile is presented to healthcare organizations and insurers. Providers are advised to adhere to specific directions, such as using blue or black ink for completion and avoiding common pitfalls that could delay the process, like illegible handwriting or incorrect formatting. Particularly noteworthy is the requirement for exactitude in the representation of personal details, professional licenses, educational qualifications, and languages spoken, emphasizing the form's role in not just validating qualifications but also in facilitating accurate communication between providers, insurers, and patients. With sections meticulously segmenting vital information — including codes for schools and specializations and instructions for documenting a provider's training and board certification status — the CAQH Provider Application form is structured to optimize clarity and precision. For those embarking on this endeavor, comprehending each section's requisites and the overall importance of accuracy can not only expedite the credentialing process but also enhance the reliability of data shared across the healthcare ecosystem.

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Provider Application

CAQH AUTOMATICALLY APPLIES MIXED-CASE FORMATTING,

CORRECT NUMBERS

CORRECT

INCORRECT

•

COMMON ABBREVIATIONS, AND ZIP CODE MATCHING. PLEASE

AND LETTERS

MARK

MARKS

MAKE CORRECTIONS ONLINE OR CALL THE HELP DESK.

Instructions

Tips to avoid processing delays

Read all instructions

Complete only this application and its supplemental forms. Do not use another provider’s application.

Use a blue or black ink ball-point pen only. Do not use a pencil or a felt-tip pen.

carefully prior to

Print legibly and inside the boxes provided based upon the examples given above.

submitting your

Do not enter more than 1 character per box. If necessary, write outside the provided spaces.

application.

Complete all sections that are applicable to you.

6. Some fields use “codes” to help you easily report information (e.g., schools, languages). Code lists are found on pages 36 - 43.

NOTE: Fields with asterisks (*) indicate that a response is required. All other fields will be considered not applicable if left blank.

SECTION 1

Personal Information and Professional IDs

Provider Type

Code list is found on page 36. Enter the

DO YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING?*

associated 3-digit code in the space

YES

(E.G. PATHOLOGISTS, ANESTHESIOLOGISTS, ER PHYSICIANS, NURSE

provided.*

PRACTITIONER, RADIOLOGISTS, PHYSICIAN ASSISTANT, ETC.)

Name

Do not use nicknames

or initials, unless they

LAST NAME*

SUFFIX (JR, III)

are part of your legal

name.

FIRST NAME*

MIDDLE NAME

HAVE YOU EVER USED ANOTHER NAME?*

YES

IF YES, PLEASE LIST ALL OTHER NAMES USED AND THEIR DATES OF USE BELOW.

OTHER LAST NAME

SUFFIX (JR, III)

OTHER FIRST NAME

OTHER MIDDLE NAME

DATE STARTED USING OTHER NAME

DATE STOPPED USING OTHER NAME

General

Information

GENDER*

MALE

FEMALE

DATE OF BIRTH*

Only enter a Foreign

National Identification

Number if you do not

have a SSN. Do not

enter National Provider

CITY OF BIRTH

STATE OF

COUNTRY OF

Identification (NPI)

BIRTH

Number here.

SSN*

Code lists are found on

pages 36-43. Enter the

FOREIGN NATIONAL IDENTIFICATION NUMBER (FNIN)

FNIN COUNTRY OF ISSUE

associated 3-digit code

in the space provided.

ENTER ALL NON-ENGLISH

LANGUAGES YOU SPEAK

LANGUAGE CODE

Home Address

NUMBER

STREET

APT NUMBER

CITY

STATE

ZIP CODE

TELEPHONE

NOTE: CAQH will use

this method for

E-MAIL

application follow-up.

FAX

PREFERRED METHOD OF CONTACT*

E-MAIL

FAX

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Page 01

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Section 1

Personal Information and Professional IDs (Continued)

Professional

IDs

FEDERAL DEA NUMBER

Include all state

DEA ISSUE DATE

licenses, DEA

Registration and State

Controlled Dangerous

DEA STATE OF REGISTRATION

DEA EXPIRATION DATE

Substance (CDS)

certification numbers.

Provide all current and

CDS CERTIFICATE NUMBER

CDS ISSUE DATE

previous licenses/

certifications.

CDS STATE OF REGISTRATION

CDS EXPIRATION DATE

Non-licensed

professionals should

enter certification/

registration number in

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE

the space provided for

IF THIS IS A STATE LICENSE, ARE YOU

license number.

YES

CURRENTLY PRACTICING IN THIS STATE?

If you have additional

LICENSE EXPIRATION DATE

Professional IDs to

report, use the

Code list is found on page 36;

Professional IDs

use license status codes. Enter

use provider type codes. Enter

Supplemental Form on

3-digit code in space provided.

LICENSE STATUS CODE

page 19.

LICENSE TYPE

STATE LICENSE NUMBER

LICENSE ISSUING STATE

LICENSE ISSUE DATE

IF THIS IS A STATE LICENSE, ARE YOU

YES

CURRENTLY PRACTICING IN THIS STATE?

LICENSE EXPIRATION DATE

Code list is found on page 36;

use license status codes. Enter

use provider type codes. Enter

3-digit code in space provided.

LICENSE STATUS CODE

LICENSE TYPE

Other ID

ARE YOU A PART-

YES

Numbers

ICIPATING MEDICARE

PROVIDER?*

MEDICARE NUMBER

UPIN

If you have additional

ARE YOU A PART-

Professional IDs to

ICIPATING MEDICAID

YES

report, use the

PROVIDER?*

MEDICAID NUMBER

MEDICAID STATE

Professional IDs

Supplemental Form on

page 19.

NATIONAL PROVIDER IDENTIFICATION (NPI) NUMBER

USMLE NUMBER (WITHOUT HYPHENS)

WORKERS COMPENSATION NUMBER

—

ECFMG NUMBER (NON-U.S./CANADIAN GRADUATE ONLY)

ECFMG CERTIFICATE ISSUE DATE (NON-U.S./CANADIAN GRADUATE ONLY)

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Page 02

Section 2

Education and Training

Undergraduate

UNDERGRADUATE SCHOOL

School(s)

Provide the appropriate

information for the

OFFICIAL NAME OF UNDERGRADUATE SCHOOL

school that issued your

undergraduate degree

and all schools

attended.

ADDRESS

CITY

STATE

ZIP/POSTAL CODE

Professional

School(s)

Provide the appropriate

COUNTRY CODE

TELEPHONE

FAX

information for the

school that issued your

professional degree.

START DATE

END DATE (GRADUATION DATE)

DEGREE AWARDED

Fifth Pathway Graduates

DID YOU COMPLETE YOUR

YES

please complete the

UNDERGRADUATE EDUCATION

following sections: U.S.

AT THIS SCHOOL?

School that issued your

certificate, the Non-U.S.

GRADUATE TYPE*:

School where you

attended, and the Fifth

Pathway institution

U.S. OR CANADIAN GRADUATE

NON-U.S./CANADIAN GRADUATE

FIFTH PATHWAY GRADUATE

where you completed

your training on

U.S. OR CANADIAN SCHOOL

Supplemental Page 20.

Code lists are found on

SCHOOL CODE (U.S./

NAME OF U.S./

pages 36-43. Enter the

CANADIAN ONLY)

CANADIAN SCHOOL:

associated 3-digit code

in the space provided.

If you have additional

START DATE*

END DATE (GRADUATION DATE)*

DEGREE AWARDED

Undergraduate or

Professional Schools to

DID YOU COMPLETE YOUR

report, use the

GRADUATE EDUCATION AT THIS

YES

Education Supplemental

SCHOOL?

Form on page 20.

NON - U.S. OR CANADIAN SCHOOL

OFFICIAL NAME OF NON-U.S. PROFESSIONAL SCHOOL

ADDRESS

CITY

COUNTRY CODE

POSTAL CODE

START DATE*

END DATE (GRADUATION DATE)*

DEGREE AWARDED

DID YOU COMPLETE YOUR

YES

GRADUATE EDUCATION AT THIS

SCHOOL?

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Section 2

Education and Training (Continued)

Training

List all training

SCHOOL CODE (E.G.,

programs you

AFFILIATED MEDICAL

attended. Use one

SCHOOL)

section per institution.

INSTITUTION/HOSPITAL NAME (USE BOTH LINES IF REQUIRED)

If you have additional

post-graduate training

programs, use the

NUMBER

STREET

SUITE/BUILDING

Supplemental Training

Form on page 21.

Please explain on the

CITY

STATE

ZIP/POSTAL CODE

Supplemental

Professional / Work

History Gap Form on

page 33 any training

COUNTRY CODE

TELEPHONE

FAX

gap(s) of three (3)

months or greater, or

DID YOU COMPLETE THIS TRAINING PROGRAM AT THIS

YES

any gap(s) of a shorter

INSTITUTION?

duration if required by

(IF NOT, PLEASE USE THE SPACE BELOW TO EXPLAIN.)

the organization for

which you are being

credentialed.

Code lists are found on pages 36-43. Enter the associated 3-digit code in the space provided.

List each

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

department

separately, if

START DATE

END DATE

applicable.

List

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

Internship/

Residency,

Fellowship

and Other

NAME OF DIRECTOR

programs

separately.

INTERNSHIP/

FELLOWSHIP

OTHER

RESIDENCY

START DATE

END DATE

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

INTERNSHIP/

RESIDENCY

FELLOWSHIP OTHER M M Y Y Y Y M M Y Y Y Y

START DATE

END DATE

DEPARTMENT/SPECIALTY (DO NOT ABBREVIATE)

NAME OF DIRECTOR

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Section 3

Professional / Medical Specialty Information

Primary

SPECIALTY

INITIAL

DO YOU WISH TO

HMO

YES

Specialty

CODE

CERTIFICATION

BE LISTED IN

DATE

THE DIRECTORY

RECERTIFICATION

UNDER THIS

Code lists are found on

BOARD

YES

SPECIALTY?

PPO

YES

DATE

CERTIFIED?

pages 36-43. Enter the

(IF APPLICABLE)

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

POS

YES

BOARD

(IF APPLICABLE)

CODE

IF NOT

I HAVE TAKEN

I INTEND TO SIT FOR AN

I DO NOT INTEND TO TAKE

BOARD

EXAM, RESULTS

EXAM ON

A CERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

(SELECT

ONE)

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

Secondary

SPECIALTY

INITIAL

DO YOU WISH TO

HMO

YES

Specialty

CODE

CERTIFICATION

BE LISTED IN

DATE

THE DIRECTORY

RECERTIFICATION

UNDER THIS

Code lists are found on

BOARD

YES

SPECIALTY?

PPO

YES

DATE

CERTIFIED?

pages 36-43. Enter the

(IF APPLICABLE)

associated 3-digit code

CERTIFYING

EXPIRATION DATE

in the space provided.

POS

YES

BOARD

(IF APPLICABLE)

CODE

If you have additional

IF NOT

I HAVE TAKEN

I INTEND TO SIT FOR AN

Professional / Medical

I DO NOT INTEND TO TAKE

BOARD

EXAM, RESULTS

Specialties to report,

EXAM ON

A CERTIFYING BOARD EXAM.

CERTIFIED

PENDING FOR

use the Additional

(SELECT

Specialties

ONE)

Supplemental Form on

page 22.

CERTIFYING BOARD CODE

IF YOU INDICATED THAT YOU DID NOT INTEND TO TAKE A CERTIFYING BOARD EXAM, PLEASE USE THE

FOLLOWING SPACE TO EXPLAIN, OTHERWISE LEAVE THE SPACE BLANK.

3081

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Section 3

Professional / Medical Specialty Information (Continued)

Certifications

Do you hold the following certifications? If yes, provide expiration dates.

EXPIRATION DATE

BASIC LIFE

ADV LIFE

YES

SUPPORT IN

YES

SUPPORT?*

OB?*

ADV TRAUMA

CPR?*

YES

LIFE

YES

SUPPORT?*

ADV

PEDIATRIC

CARDIAC

YES

ADVANCED

YES

LIFE SPT?*

NEONATAL

ADVANCED

YES

LIFE SPT?*

Practice

Interests

Provide additional

areas of professional

practice interest,

activities, procedures,

diagnoses or

populations.

Primary

Credentialing

Contact

LAST NAME

CHECK HERE TO

USE THE OFFICE

FIRST NAME

M.I.

MANAGER AND

ADDRESS OF THE

PRIMARY PRACTICE

LOCATION AS THE

NUMBER

STREET

SUITE/BUILDING

CREDENTIALING

INFORMATION.

CITY

STATE

ZIP CODE

NOTE:

Even if you checked

TELEPHONE

FAX

the boxes above,

please provide the

e-mail address, if

E-MAIL ADDRESS

available.

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Section 4

Practice Location Information

Primary

NOTE: IF YOU INDICATED THAT YOU PRACTICE EXCLUSIVELY WITHIN THE INPATIENT SETTING ON PAGE 1, YOU ARE ONLY REQUIRED TO COMPLETE THE

Practice

CREDENTIALING CONTACT QUESTION ABOVE. SECTION 4 MAY BE LEFT BLANK. YOU MAY PROCEED TO SECTION 5 ON PAGE 11.

Location

CURRENTLY

YES

IF NO, WHAT IS

PRACTICING AT

YOUR EXPECTED

THIS ADDRESS?*

START DATE?

If you have additional

practice locations, use

the Supplemental

PHYSICIAN GROUP / PRACTICE NAME TO APPEAR IN DIRECTORY (DO NOT ABBREVIATE)*

Practice Location

Information Form on

pages 25-29.

GROUP / CORPORATE NAME AS IT APPEARS ON W-9, IF DIFFERENT FROM ABOVE (DO NOT ABBREVIATE)

NOTE: “General

Correspondence” refers

to any correspondence

NUMBER*

STREET*

SUITE/BUILDING

that might be sent to the

provider that does not

solely relate to creden-

CITY*

STATE*

ZIP CODE*

tialing or billing

information.

SEND GENERAL

YES

CORRESPON-

TIP Your Individual Tax

DENCE HERE?*

TELEPHONE*

FAX

ID is assumed to be

your Primary Tax ID

unless you specify

otherwise to the right.

OFFICE E-MAIL ADDRESS

PRIMARY

USE INDIVIDUAL

USE GROUP

TAX ID

(ONE ONLY)*

INDIVIDUAL TAX ID

GROUP TAX ID

Office Manager

or Business

Office Staff

LAST NAME*

Contact

List each contact

FIRST NAME*

M.I.

separately. You may

use the check boxes

below for convenience.

TELEPHONE*

FAX

Do not write

instructions like “see

above”. These

responses will be

E-MAIL ADDRESS

rejected and will

require follow-up.

Billing Contact

LAST NAME*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

FIRST NAME*

M.I.

AS BILLING

INFORMATION

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Billing Contact.

E-MAIL ADDRESS

3083

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*REQUIRED RESPONSE. NO RESPONSE MAY CAUSE PROCESSING DELAYS AND REQUIRE FOLLOW-UP.

Section 4

Practice Location Information (Continued)

Payment and

ELECTRONIC

YES

Remittance

BILLING

CAPABILITIES?*

BILLING DEPARTMENT (IF HOSPITAL-BASED)

YOUR “CHECK PAYABLE TO”

INFORMATION SHOULD BE

CONSISTENT WITH YOUR

W-9.

CHECK PAYABLE TO*

CHECK HERE TO

USE OFFICE

MANAGER AND

OFFICE ADDRESS

LAST NAME*

AS PAYEE

INFORMATION

FIRST NAME*

M.I.

NUMBER*

STREET*

SUITE/BUILDING

NOTE:

Even if you checked

CITY*

STATE*

ZIP CODE*

the box above, please

provide the

E-mail Address of the

TELEPHONE*

FAX

Payee Contact.

E-MAIL ADDRESS

Office Hours

(USE HHMM FORMAT AND ROUND TO THE NEAREST HALF-HOUR)

START

A=AM

END

A=AM

START

A=AM

END

A=AM

P=PM

MONDAY

FRIDAY

TUESDAY

SATURDAY

WEDNESDAY

SUNDAY

NOTE:

THURSDAY

After hours back office

telephone will be used

only by the health plan

24/7 PHONE COVERAGE?*

IF YES

AFTER HOURS BACK OFFICE TELEPHONE

and will not be

ANSWERING

VOICE MAIL WITH

VOICE MAIL

published under any

YES

INSTRUCTIONS TO CALL

WITH OTHER

SERVICE

circumstances.

ANSWERING SERVICE

INSTRUCTIONS

Open Practice

ACCEPT NEW PATIENTS INTO THIS PRACTICE?*

YES

ACCEPT ALL NEW PATIENTS?*

YES

Status

ACCEPT EXISTING PATIENTS WITH CHANGE OF PAYOR?*

YES

ACCEPT NEW MEDICARE PATIENTS?*

YES

ACCEPT NEW PATIENTS WITH PHYSICIAN REFERRAL?*

YES

ACCEPT NEW MEDICAID PATIENTS?*

YES

IF ANY OF THE

ABOVE INFORMATION

VARIES BY PLAN,

EXPLAIN (USE BOTH

LINES IF REQUIRED)

ARE THERE ANY

GENDER LIMITATIONS

AGE LIMITATIONS

LIST OTHER LIMITATIONS

PRACTICE LIMITATIONS?*

MALE

MINIMUM

ONLY

NONE

AGE

YES

IF YES

FEMALE

MAXIMUM

ONLY

AGE

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Section 4

Practice Location Information (Continued)

Mid-Level

DO MID-LEVEL PRACTITIONERS (NURSE PRACTITIONERS, PHYSICIAN

YES

ASSISTANTS, ETC.) CARE FOR PATIENTS IN YOUR PRACTICE?*

Practitioners

(IF YES, PLEASE PROVIDE THE INFORMATION BELOW)

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

PRACTITIONER LAST NAME

PRACTITIONER FIRST NAME

M.I.

PRACTITIONER TYPE (E.G., PA,

CNP, NP)

PRACTITIONER LICENSE / CERTIFICATE NUMBER

PRACTITIONER STATE

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Section 4

Practice Location Information (Continued)

Languages

LANGUAGES

NON-ENGLISH LANGUAGES

Code lists are found on

SPOKEN BY OFFICE PERSONNEL

pages 37. Enter the

LANGUAGE CODE

associated 3-digit code

in the space provided.

INTERPRETERS

YES

LANGUAGES

AVAILABLE?*

INTERPRETED

LANGUAGE CODE

Accessibilities

DOES THIS OFFICE MEET ADA ACCESSIBILITY REQUIREMENTS?*

YES

DOES THIS SITE OFFER HANDICAPPED

DOES THIS SITE OFFER OTHER

YES

ACCESSIBLE BY

YES

ACCESS FOR THE FOLLOWING

SERVICES FOR THE DISABLED?*

PUBLIC TRANSPORTATION?*

YES

BUS*

YES

BUILDING?*

TEXT TELEPHONY (TTY)*

YES

PARKING?*

YES

AMERICAN SIGN LANGUAGE*

YES

SUBWAY*

MENTAL/PHYSICAL IMPAIRMENT

REGIONAL TRAIN*

YES

RESTROOM?*

YES

SERVICES*

OTHER HANDICAPPED ACCESS

OTHER DISABILITY SERVICES

OTHER TRANSPORTATION ACCESS

Services

Does this location provide any of the following services?

LABORATORY

IF YES, PROVIDE ACCREDITING/

YES

CERTIFYING PROGRAM

SERVICES?

(E.G., CLIA, COLA, MLE)

RADIOLOGY

YES

IF YES, PROVIDE X-RAY

SERVICES?

CERTIFICATION TYPE

EKGS?

YES

ALLERGY

YES

ALLERGY SKIN

YES

ROUTINE OFFICE

YES

GYNECOLOGY

INJECTIONS?

TESTING?

(PELVIC/PAP)?

AGE

DRAWING

YES

FLEXIBLE

YES

TYMPANOMETR

YES

BLOOD?

APPROPRIATE

Y/ AUDIOMETRY

IMMUNIZATIONS?

SIGMOIDOSCOPY?

SCREENING?

ASTHMA

YES

OSTEOPATHIC

YES

IV HYDRATION/

YES

CARDIAC

YES

TREATMENT?

MANIPULATION?

TREATMENT?

STRESS TEST?

PULMONARY

YES

PHYSICAL

YES

CARE OF MINOR

YES

FUNCTION

THERAPY?

LACERATIONS?

TESTING?

IF YES, WHAT

IS ANESTHESIA

ADMINISTERED IN

YES

CLASS/CATEGORY

YOUR OFFICE?

DO YOU USE?

IF YES, WHO

ADMINISTERS IT?

LAST NAME

FIRST NAME

TYPE OF PRACTICE

SOLO PRACTICE

SINGLE SPECIALTY GROUP

MULTI-SPECIALTY GROUP

(SELECT ONE ONLY)*

ADDITIONAL OFFICE PROCEDURES PROVIDED (INCLUDING SURGICAL PROCEDURES)

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Document Attributes

Fact Number	Fact Name	Description
1	Form Purpose	The CAQH Provider Application is designed to standardize and simplify the collection of information required by health plans, hospitals, and other healthcare organizations.
2	Writing Requirements	Applicants must use a blue or black ink ball-point pen for completion and ensure legibility throughout.
3	Formatting Precision	Entries must be made with careful attention to provided boxes, with only one character per box to ensure accuracy and readability.
4	Mandatory Fields	Fields marked with an asterisk (*) are required, indicating a response is necessary for the application to be processed.
5	Use of Codes	Certain sections require the use of specific codes for reporting information, such as for schools or languages, with lists provided within the application documentation.
6	Personal and Professional IDs	Section 1 demands detailed personal information and professional identifiers, emphasizing the importance of accurate data for identification and verification purposes.
7	Education and Training Documentation	Applicants must furnish comprehensive educational and postgraduate training history, including institutions, degrees, and certification details.
8	Professional Licenses and IDs	Extensive information about state licenses, DEA certifications, and other professional ID numbers is required to validate the applicant's qualifications.
9	Specialty Information	Providers need to list their specialty(ies) and board certification(s), illustrating their specific area(s) of expertise within healthcare.
10	Contact Preferences	CAQH uses provided contact information as the primary mode of communication for application follow-ups, emphasizing the need for updated and preferred contact details.

How to Fill Out Caqh Provider Application

Filling out the CAQH Provider Application form is essential for healthcare providers seeking to streamline their credentialing process, ensuring they can effectively offer their services through various networks. This detailed walkthrough is designed to guide providers through the process, simplifying the complex steps involved in completing the form. Following these instructions diligently can help avoid common pitfalls that delay processing.

Read all provided instructions carefully before you start the application to prevent any processing delays.
Ensure you use this form exclusively; do not repurpose or modify another provider’s application.
For all written sections, only use blue or black ink ballpoint pens. Pencils or felt-tip pens are not acceptable.
Print your responses legibly within the boxes provided, referring to the examples given on the form. Enter only one character per box, and if necessary, write outside the provided spaces.
Complete every section applicable to your professional and personal information. If a section does not apply to you, leave it blank.
Refer to the codes found on pages 36 - 43 for specific fields that require them (e.g., schools, languages), entering the associated 3-digit code in the space provided. Note that some fields, marked with an asterisk (*), are mandatory and require a response.
In the Personal Information and Professional IDs section, do not use nicknames or initials unless they are part of your legal name. Make sure to indicate if you have ever used another name and provide details.
When entering your general information, only include a Foreign National Identification Number if you do not have an SSN and avoid putting the National Provider Identification (NPI) Number in this section.
For your home address, ensure it's fully filled out as CAQH will utilize this for any application follow-ups, specifying your preferred method of contact.
Under Professional IDs, include all relevant state license numbers, DEA registration, and any certification numbers. Utilize the supplemental forms if you have more IDs to report than the space allows.
In the Education and Training section, furnish details of your undergraduate, professional schools, and any postgraduate training like internships and fellowships, using supplementary pages if the space provided is insufficient.
For Professional/Medical Specialty Information, input the appropriate specialty codes and certification details, indicating whether you wish to be listed under each specialty in the directory. Use additional forms if reporting more than one specialty.

Once completed, review the entire form to ensure all information is accurate and all necessary sections are filled. Submit the application following the instructions provided by CAQH, paying attention to any specific submission requirements or deadlines. The successful completion and submission of your CAQH Provider Application form is a crucial step towards simplifying the credentialing process, facilitating smoother interactions with insurance networks and ultimately benefitting your practice.

More About Caqh Provider Application

What is mixed-case formatting on the CAQH Provider Application form, and how does it apply to my application?

Mixed-case formatting is a feature that automatically adjusts the casing of letters (i.e., uppercase and lowercase) in your application. This ensures that names, addresses, and other important details are correctly formatted, enhancing the readability and professionalism of your application. When you enter your information, for example, "john doe" would automatically adjust to "John Doe". This formatting applies to most fields where text is entered and is part of the form's attempt to standardize the appearance of applications for easier processing and review.
How do I ensure my application does not experience processing delays?

To avoid processing delays, adhere to the following guidelines: First, complete the application and any supplemental forms using blue or black ink only, ensuring all print is legible and confined to the boxes provided. Make sure to enter only one character per box and complete all sections that apply to your situation. Utilize the provided code lists for fields requiring codes, such as school codes or language codes. Importantly, any field marked with an asterisk (*) requires a response; leaving these fields blank may lead to delays and necessitate follow-up communication.
What should I do if I practice exclusively within an inpatient setting?

If you practice exclusively within an inpatient setting, such as a hospital, indicate this by selecting "Yes" in response to the related question on the form. This information is critical for accurately processing your application, as it helps to clarify the nature of your practice environment. This is especially relevant for certain specialties where clinicians are more likely to operate within inpatient settings, such as pathologists, anesthesiologists, and emergency room physicians.
What if I have another name or have used one in the past?

If you have used another name, either currently or in the past, it is important to disclose this information on the application. Select "Yes" in response to the question about using other names, and then list all other names you have used, along with the dates during which each was used. This information is crucial for verification purposes and ensures that all records and credentials can be accurately associated with you, regardless of the name under which they were obtained.

Common mistakes

Filling out the CAQH Provider Application form is a crucial step for healthcare providers looking to streamline the credentialing process. However, common mistakes can delay this process. Here's a list of eight common errors and tips on how to avoid them:

Using incorrect writing tools: Applicants should only use a blue or black ink ball-point pen as using a pencil or a felt-tip pen can make the application difficult to read and process.
Illegible handwriting: It’s essential to print legibly inside the boxes provided. Illegible handwriting can lead to misinterpretation of information and subsequent processing delays.
Overcrowding information: Do not enter more than 1 character per box. If necessary, continue writing outside the provided spaces to ensure clarity.
Skipping sections: Some applicants skip sections that are applicable to them, perhaps due to oversight. Every applicable section should be completed for accurate processing.
Incorrect use of codes: The form uses various “codes” for fields like schools and languages. Applicants often incorrectly fill these out or overlook the code lists on pages 36 - 43.
Incomplete personal information: Failing to provide complete personal information, especially not inputting a legal name in full or neglecting to list any other names used, can cause delays.
Leaving mandatory fields blank: Fields marked with an asterisk (*) require a response. Not filling these mandatory fields can halt the application process and necessitate follow-up.
Inaccurately reporting professional IDs: In the section for Professional IDs, some applicants neglect to include all pertinent state licenses, DEA numbers, or fail to accurately report if they're currently practicing in the state associated with a given license. This omission or inaccuracy can significantly delay verification processes.

By paying careful attention to these common pitfalls, applicants can ensure a smoother credentialing process. Always review the application in its entirety before submission to verify that all information is correct and complete.

Documents used along the form

The CAQH Provider Application is a crucial document for healthcare providers seeking to streamline their credentialing process, ensuring accuracy and efficiency in their professional data management. Completing this form is only the beginning, as several additional documents are typically required to accompany the CAQH application to provide a comprehensive profile of the provider's qualifications, identity, and professional background. Below are several of these documents, each serving a specific purpose in the credentialing process:

Curriculum Vitae (CV) or Resume: This document provides a detailed overview of the provider's educational background, work history, certifications, and achievements. It is essential for credentialing committees to assess the provider's qualifications and professional journey.
Professional Licenses: Copies of current professional licenses are necessary to verify the provider's legal authority to practice within their state or jurisdiction. This includes any specialty or sub-specialty licenses.
Board Certification Documentation: Evidence of board certification in the provider's specialty demonstrates that they have met the rigorous standards and qualifications set by their specialty board.
Drug Enforcement Administration (DEA) Certificate: For providers authorized to prescribe controlled substances, a current DEA certificate is required to verify this authority.
Malpractice Insurance Certificate: Documentation of the provider's current malpractice insurance policy is needed to confirm coverage, ensuring they are protected against liability claims.
Continuing Education Certificates: These certificates prove the provider's commitment to continuing education and staying updated on the latest in their field, a requirement for maintaining board certification and licensure.
Government Issued ID: A copy of a government-issued identification document (e.g., Drivers License, Passport) is often required to verify the identity of the provider.

Together, these documents complement the CAQH Provider Application by providing a full picture of the provider's professional and legal standing. It is advisable for providers to gather these documents in advance to ensure a smooth and uninterrupted credentialing process. Ensuring each document is current and accurately reflects the provider's qualifications and status is crucial for a successful application submission.

Similar forms

The Medical Licensing Application used by state medical boards is similar because it also gathers detailed professional, educational, and personal background information to ensure a practitioner meets the necessary qualifications.
The DEA Registration Application shares similarities with the CAQH Provider Application by requiring detailed professional IDs and certifications essential for prescribing controlled substances.
The National Provider Identifier (NPI) Application aligns closely with the CAQH form in collecting the provider's personal and professional identification data to assign a unique healthcare provider identifier.
The Hospital Privileging Application is comparable as it also collects comprehensive data on a healthcare provider's education, training, and specialty area to grant privileges for practicing in a hospital setting.
An Insurance Panel Credentialing Form parallels the CAQH Provider Application by requiring detailed professional information to assess whether a healthcare provider meets an insurer's criteria for joining their network.
The Fellowship Application Forms for medical fellows share characteristics in requiring detailed educational and training histories to evaluate the applicant's suitability for advanced medical training programs.
Visa Screening Applications for healthcare professionals looking to practice in another country require similar comprehensive professional profile information to ensure the practitioner's qualifications meet the host country's standards.
A Professional Association Membership Application mirrors the CAQH application in collecting detailed professional information to determine eligibility for membership based on professional credentials and areas of specialty.
State Controlled Dangerous Substances (CDS) Registration Forms, like the CAQH application, require detailed information about the healthcare provider's licensure and eligibility to handle controlled substances within a state.
The Continuing Medical Education (CME) Reporting Forms are somewhat similar because they too require detailed professional information, including education and training, to verify that a healthcare provider meets ongoing education requirements within their specialty.

Dos and Don'ts

When completing the CAQH Provider Application form, ensuring accuracy and thoroughness is key to avoiding processing delays. The following are essential dos and don'ts to consider:

Do read all instructions carefully before you start filling out the application to ensure you understand the requirements.
Do use a blue or black ink ball-point pen for clarity and legibility.
Do print legibly and within the boxes provided, following the examples for formatting to avoid any confusion.
Do complete all sections that apply to you, ensuring that no required field is left blank.
Don't use a pencil or felt-tip pen as these can smudge or fade, making your application difficult to read.
Don't enter more than one character per box. If you run out of space, complete your entry outside the provided fields if necessary.
Don't leave fields with asterisks (*) blank; these indicate a required response, and omitting this information can lead to delays.
Don't use another provider’s application form or include supplemental forms not requested, as this can cause confusion and further delay processing.

By following these guidelines, you help ensure that your application is processed smoothly and without unnecessary delay. Always double-check your entries for accuracy and completeness before submission. If you encounter any difficulties or have questions, contacting the help desk as noted in the application instructions can provide additional guidance.

Misconceptions

One common misconception is that the CAQH Provider Application can accommodate multiple characters or symbols within a single box. However, the form explicitly requires that only one character be entered per box to avoid processing errors. If more space is needed, the application instruction advises to write outside the provided spaces.
Many believe that leaving fields blank will not impact the processing of their application. This is not accurate, as fields marked with an asterisk (*) are mandatory. Failure to respond to these required fields may lead to processing delays and necessitate follow-up communication, potentially hindering timely approval of the application.
There's a false assumption that if you don't have a Social Security Number (SSN) you cannot complete the Provider Type or Professional IDs section of the application. For individuals without an SSN, the form provides an alternative, allowing the entry of a Foreign National Identification Number (FNIN), ensuring that applicants without an SSN can still proceed with their application.
Another incorrect belief is that the application form restricts the reporting of professional IDs to only state licenses. The form is designed to capture a wide range of professional identifiers, including but not limited to federal DEA numbers, State Controlled Dangerous Substances (CDS) certification numbers, Medicare and Medicaid numbers, in addition to any state license numbers. This comprehensive approach is intended to collate all essential identifiers that collectively facilitate the providers' credentialing process.

Key takeaways

Understanding the CAQH Provider Application form is crucial for healthcare providers seeking credentialing or to update their professional profile. Here are six key takeaways to help you navigate the process seamlessly:

Attention to Detail: When filling out the CAQH form, it's imperative to use a blue or black ink ball-point pen. This ensures clarity and avoids any processing delays due to illegible entries. Each character must be contained within the boxes provided, adhering to the examples shown to avoid corrections.
Completeness: Make sure to complete all sections that are applicable to your situation. Fields marked with asterisks (*) require a response, and leaving them blank could result in processing delays. It's better to review each section carefully rather than assume they do not apply.
Use of Codes: The CAQH form utilizes codes for a streamlined filling process, especially for reporting information such as schools and languages. These codes can be found within the form instructions, and correctly using them simplifies the submission while reducing the potential for errors.
Personal and Professional Information: It's crucial to provide accurate personal information and professional IDs. This includes not using nicknames or initials unless they are part of your legal name. Also, ensure all professional identification numbers, like state licenses and DEA numbers, are current and correctly entered.
Educational and Training Information: For the education and training sections, providing comprehensive details about your undergraduate, graduate, and any post-graduate training is necessary. List all relevant schools, programs, and certificates, including the exact dates and any special conditions or explanations if you did not complete a program.
Specialty Information: Clearly indicate your medical specialty, including any board certifications. If you intend to sit for a board exam or if results are pending, make this clear. If you do not plan to take a certifying board exam, provide a brief explanation. This section helps define your professional scope and ensures accurate representation to potential employers or patients.

Thoroughly reviewing and accurately completing the CAQH Provider Application form is a foundational step for healthcare providers to participate in various networks or to maintain their professional credentials. By following the detailed instructions and taking care to provide complete and precise information, you can streamline the credentialing process and avoid unnecessary delays.

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