Free Caqh Provider Application Form in PDF

The CAQH Provider Application Form is a standardized document designed to simplify the process of credentialing for healthcare providers. It requires providers to fill in various types of personal and professional information, from basic contact details and professional IDs to education, training, and specialty certification. Ensuring that this application is filled out accurately and completely is crucial to avoid processing delays and expedite credentialing with healthcare organizations and insurance networks. To begin the submission process or for more assistance, consider clicking the button below.

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The CAQH Provider Application form is an essential document for healthcare providers seeking to streamline their credentialing process. Ensuring the form is correctly filled out is paramount to avoiding processing delays, which is why CAQH emphasizes the importance of reading all instructions carefully before submission. Applicants are instructed to use only the application and its supplemental forms designed for them, utilize blue or black ink for clarity, and print legibly within the provided spaces. Mistakes like entering more than one character per box or not completing all applicable sections can lead to processing delays. Specific fields marked with asterisks require a response, highlighting their critical nature in the application's completion. Additionally, the form systematizes data entry through the use of codes for easy reporting of information, such as schools attended and languages spoken, with code lists provided within the form itself. From personal and professional identification details to educational background and training experiences, the form covers a comprehensive range of information necessary for the credentialing process. Furthermore, professional and medical specialty information is captured, including board certifications and affiliations with healthcare organizations. By adhering to the detailed instructions and completing the application accurately, providers can facilitate a smoother credentialing process, enabling them to deliver healthcare services without unnecessary administrative hindrances.

Preview - Caqh Provider Application Form

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.

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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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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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▼ PDF

Document Specs

Fact	Details
Formatting Instructions	The CAQH Provider Application automates mixed-case formatting, corrects number sequences, applies common abbreviations, and matches ZIP codes, prompting providers to make corrections online or call the help desk for errors.
Required Writing Instruments	Applicants must use a blue or black ink ball-point pen exclusively, as pencils and felt-tip pens are not permissible for completing the form.
Input and Legibility Guidelines	Only one character per box is allowed to maintain legibility and accuracy, with clear instructions to print legibly inside the boxes provided, citing specific examples for clarity.
Completion and Code Use	All applicable sections must be completed by the applicant, utilizing “codes” found within the form (pages 36 - 43) to report information efficiently (e.g., schools, languages), with asterisked (*) fields indicating mandatory responses to avoid processing delays.

Instructions on Writing Caqh Provider Application

Filling out the CAQH Provider Application form requires attention to detail to ensure accurate and complete submission. The following steps are designed to guide applicants through the process efficiently. Taking the time to carefully follow these instructions will help avoid processing delays and ensure your application is reviewed promptly.

Before starting, gather all necessary information including professional identification numbers, educational history, and personal details to ensure a smooth process.
Use a blue or black ink ball-point pen to fill out the form. Other types of pens or pencils are not accepted.
Print legibly in the boxes provided, ensuring only one character is entered per box. Refer to the examples given in the form if needed.
Complete all sections that are applicable to you. If a field is not applicable, leave it blank unless it is marked with an asterisk (*), indicating a required response.
For sections requiring codes (e.g., schools, languages), refer to the code lists provided between pages 36 and 43 of the application.
In the Personal Information and Professional IDs section, enter your full legal name without nicknames or initials unless they are part of your legal name. Also, ensure to provide complete details regarding your practicing status, gender, date of birth, and complete home address.
Under Professional IDs, include all relevant numbers such as state DEA licenses, DEA Registration, Controlled Dangerous Substance (CDS) certification numbers, and any additional professional identification numbers. Use the Professional IDs Supplemental Form on page 19 for any additional IDs that need to be reported.
In the Education and Training section, provide details of your undergraduate and professional schools, including names, addresses, and dates attended. For post-graduate training, list all programs attended using separate sections for each institution and complete the Supplemental Training Form on page 21 for any additional programs.
The Professional / Medical Specialty Information section requires information about your primary and secondary specialties, including specialty code, initial certification date, and certifying board information. If you have more than one specialty, use the Additional Specialties Supplemental Form on page 22.
Once all the required information is provided, review the application thoroughly to ensure accuracy and completeness.
Submit the completed application as directed in the form instructions, ensuring to include any supplementary forms that are applicable to your application.

After submitting your application, it will be reviewed for completeness and accuracy. You may be contacted for additional information or clarification if needed. Promptly responding to any inquiries from CAQH will help expedite the review process. It is crucial to stay informed about the status of your application and follow up as necessary to ensure timely processing.

Understanding Caqh Provider Application

What is the CAQH Provider Application form?

The CAQH Provider Application form is a standardized document used by healthcare providers to submit their personal information, professional credentials, and details about their education and training. It is designed to streamline the process of credentialing with insurance companies and other healthcare organizations.

Why is it important to use a blue or black ink ball-point pen for the application?

Using a blue or black ink ball-point pen ensures that the application is legible and withstands the processing and scanning procedures. Pencils and felt-tip pens can smudge or fade, leading to processing delays or the need for re-submission.

Can I enter more than one character per box when filling out the form?

No, one should not enter more than one character per box to maintain clarity and prevent any information from being misinterpreted during processing. If necessary, additional information can be written outside the provided spaces as indicated in the instructions.

What should I do if I have used another name professionally or personally?

If you have used another name in the past, it is important to list all other names used along with their dates of use. This ensures that all of your professional records and credentials are accurately matched and verified without delays.

How do I indicate if I practice exclusively within the inpatient setting?

On the form, you will find a specific question asking if you practice exclusively within the inpatient setting. Indicate 'Yes' if you are specialists such as pathologists, anesthesiologists, or work mainly in a hospital. Informing about your practice setting helps streamline the credentialing process for appropriate healthcare environments.

What is the significance of the asterisks (*) found on certain fields in the application?

Fields marked with an asterisk (*) are mandatory. Failing to provide information in these fields may cause processing delays and require follow-up, as these details are crucial for the credentialing process.

How are code lists used in the CAQH Provider Application form?

The application uses codes to report information efficiently, such as schools attended, languages spoken, and provider type. Code lists are provided within the application instructions, helping to streamline the application process and ensuring consistent data entry.

What should I do if I have additional professional IDs or educational information to report?

If you have more professional IDs or educational details than the space provided on the form allows, you should use the Professional IDs Supplemental Form and the Education Supplemental Form provided on pages 19 and 20, respectively. This ensures all relevant credentials and educational background are fully documented and considered during credentialing.

Common mistakes

Filling out the CAQH Provider Application form is a meticulous process that requires attention to detail. One common mistake is not using the correct writing instrument. The instructions explicitly state to use a blue or black ink ball-point pen. Using any other kind of pen, including pencils or felt-tip pens, can cause processing delays.

Another frequent error is the manner in which the information is inputted into the form. Applicants are instructed to print legibly and ensure that only one character is entered per box. Overlooking this instruction can lead to unreadable applications, which may necessitate corrections and lead to delays.

Applicants often miss completing all sections that are applicable to them. Every field marked with an asterisk (*) requires a response. Ignoring these fields or assuming they’re not applicable can lead to incomplete applications, requiring follow-up and further delaying the processing time.

Incorrect use of abbreviations is also a common challenge. Although the form applies mixed-case formatting, correct numbers, common abbreviations, and zip code matching, applicants sometimes use unauthorized abbreviations which can confuse the reviewing process.

Another mistake lies in the handling of professional identification numbers. The form asks for various IDs, including state licenses and DEA Registration numbers. Mixing up these numbers or incorrectly entering them can lead to significant processing delays, as these are crucial for verification purposes.

Not utilizing the provided code lists for fields such as schools, languages, provider type, and specialties is another oversight. These codes are designed to standardize the information entered, and failing to use them can result in incorrect data processing.

Entering more than one character per box, when the instructions clearly state otherwise, can cause misalignment and misinterpretation of the information. This mistake can lead to incorrect data capture and necessitate manual review or corrections by the help desk.

Forgetting to list all names previously used, including maiden or former names, is a common oversight. This information is vital for a comprehensive background check and verification of credentials and professional history.

A significant mistake is not accurately reporting professional IDs or certifications. If an applicant has more than one state license or certification, each one must be reported using the supplemental forms provided. Failing to report all relevant IDs can misrepresent the applicant’s qualifications and licensure status.

Finally, applicants often incorrectly assume that leaving fields blank will not have consequences. However, as the form indicates, “No response may cause processing delays and require follow-up.” It's critical to approach the form with the understanding that all relevant sections must be completed to avoid unnecessary delays in the application process.

Documents used along the form

Completing the CAQH Provider Application is a significant step in the credentialing process for healthcare providers. This application is pivotal for establishing your eligibility to provide services for various health plans and insurance networks. However, it's rarely done in isolation. To ensure a comprehensive and smooth credentialing journey, several additional forms and documents are often required alongside the CAQH Provider Application. Understanding these supplemental materials can help you prepare effectively and avoid any delays in the process.

Curriculum Vitae (CV): Provides a detailed overview of the provider's educational background, work history, certifications, and professional accomplishments.
State Medical License: Verifies the provider's eligibility to practice medicine in a specific state. This document must be current and unrestricted.
Federal DEA Certificate: Essential for providers who prescribe medication, it proves the provider's eligibility to handle controlled substances.
Board Certification Proof: Documents certifying the provider's expertise in a particular medical specialty or specialties, awarded by a recognized specialty board.
Malpractice Insurance Certificate: Demonstrates that the provider has liability coverage, protecting against potential malpractice claims.
Medical School Diploma: Confirms the provider's completion of medical school, a fundamental requirement for practice.
Completed W-9 Tax Form: A tax document required for all U.S. providers, indicating their tax identification number and certification.
Continuing Medical Education (CME) Certificates: Verifies that the provider has participated in ongoing education to maintain their license and stay updated with medical advancements.
Professional References: Letters or contact information for peers and supervisors who can attest to the provider's competence and ethical standards.
Clinical Privileges Documentation: If applicable, proof of the provider's authorization to perform specific procedures or services at a healthcare facility.

Acknowledging and gathering these essential documents can streamline the credentialing process, easing the path to acceptance by insurance panels and health networks. Each document plays a distinct role in building a thorough profile of the healthcare provider, showcasing qualifications, competency, and commitment to compliance and patient care. By preparing these forms and documents thoughtfully and meticulously, providers can navigate the credentialing landscape more efficiently and with greater confidence.

Similar forms

The Medical Staff Application Form used by hospitals and healthcare systems shares similarities with the CAQH Provider Application form, focusing on collecting detailed information about a healthcare provider's credentials, education, training, and professional experience. Both documents require the healthcare provider to provide comprehensive personal information, detail their professional education and training, list state licenses and certifications, and disclose any specialty certifications. This thorough collection of information helps streamline the credentialing and privileging process in healthcare facilities.

The National Provider Identifier (NPI) Application is another document closely related to the CAQH Provider Application, as both require detailed personal and professional information from healthcare providers. The NPI application is designed to assign a unique identification number to healthcare providers in the U.S., which is required for billing and transaction purposes under HIPAA. Similar to the CAQH application, it collects information on the provider's qualifications, areas of practice, and compliance with federal regulations.

The DEA (Drug Enforcement Administration) Registration Form is also analogous to the CAQH Provider Application in that it collects professional information from healthcare providers who prescribe controlled substances. Both forms gather detailed information about the provider's professional credentials and legal authority to practice in their field. However, the DEA form specifically focuses on the provider's eligibility to handle controlled substances, while the CAQH form has a broader focus on general credentialing for healthcare providers.

State Medical License Application Forms, while varying from state to state, share a core objective with the CAQH Provider Application form: to verify the credentials and qualifications of healthcare providers. These state-specific forms require details about education, training, and any special certifications, mirroring the comprehensive approach of the CAQH application in assessing professional credentials for the purpose of state licensure.

The Board Certification Application Forms from various medical specialty boards resemble the CAQH Provider Application in their focus on certifying the provider's qualifications and expertise in specific areas of medicine. Both types of applications require detailed documentation of education, training, and past work experience to establish the provider's eligibility for board certification or credentialing. The main distinction lies in the specialized focus of board certification applications on specific medical specialties.

Professional Liability Insurance Applications also share similarities with the CAQH Provider Application, as they require healthcare professionals to disclose extensive background information, including professional experience, education, and any prior malpractice claims. This alignment in required information underscores the importance of understanding a provider's professional history and risk profile, both for credentialing purposes and for assessing insurance liability and coverage needs.

The Provider Enrollment, Chain, and Ownership System (PECOS) forms used by Medicare resemble the CAQH Provider Application in gathering detailed provider information to establish eligibility for Medicare billing. Both forms seek extensive details about the provider’s education, training, and licensure to ensure compliance with federal healthcare program standards. The primary aim is to validate the provider's qualifications for participation in federally funded healthcare programs.

Continuing Medical Education (CME) reporting forms, required for maintaining medical licensure and board certification, also parallel the CAQH Provider Application. Both documentations emphasize the ongoing education and training of healthcare providers. CME forms specifically document completed educational activities to maintain and update professional knowledge and skills, aligning with the CAQH application's goal of ensuring providers meet current healthcare standards.

The JCAHO (Joint Commission on Accreditation of Healthcare Organizations) Credentialing Form serves a similar purpose as the CAQH Provider Application by collecting comprehensive information to assess providers' qualifications and competencies to deliver safe and effective care. Both forms are integral to the credentialing process in healthcare settings, ensuring that providers meet the rigorous standards required to practice in accredited facilities.

Dos and Don'ts

When filling out the CAQH Provider Application form, it’s crucial to follow certain dos and don’ts to ensure the process goes smoothly. By paying attention to these guidelines, you can avoid common mistakes and delays.

Do:

Read all instructions carefully before starting the application to avoid any mistakes that could delay processing.
Use blue or black ink when completing the form to ensure clarity and legibility.
Ensure all information is printed legibly and within the boxes provided, following the examples given to guide you.
Complete all applicable sections; if a section is not relevant to you, understand that leaving it blank will indicate it’s not applicable.
Refer to pages 36 - 43 for codes needed for certain fields, such as schools and languages, to accurately report information.

Don’t:

Use another provider’s application or forms not specifically designated for this process, as each provider's information is unique.
Attempt to use a pencil or felt-tip pen because these can smudge or fade, making your application difficult to read.
Enter more than one character per box unless you're instructed to write outside the provided spaces due to space limitations.
Use nicknames or initials unless they are part of your legal name. Always provide your full legal name as it appears on official documents.
Leave required fields with asterisks (*) blank since each required response is crucial for the processing of your application.

By following these do’s and don’ts, you’ll help ensure that your CAQH Provider Application is completed accurately and processed without unnecessary delays. Remember, if you have any questions or need clarification, calling the help desk is always a good step to ensure you’re filling out the form correctly.

Misconceptions

When it comes to completing the CAQH Provider Application form, there are several misconceptions that can lead to mistakes and delays in the process. It's important to have accurate information before you begin. Here are eight common misconceptions explained:

Misconception 1: Any pen color is fine.
Contrary to this belief, only blue or black ink ball-point pens should be used for filling out the form to ensure legibility and avoid processing issues.
Misconception 2: It’s okay to use a pencil or felt-tip pen.
In fact, these writing instruments are not suitable as they can smear or fade, which can lead to data being misread during processing.
Misconception 3: Printing outside the boxes is not allowed.
While entrants are encouraged to print legibly inside the boxes, if necessary, writing outside the provided spaces is permissible.
Misconception 4: Nicknames or initials are acceptable for the name fields.
Actually, the name used should match your legal name, unless the nickname or initials are part of your legal identity.
Misconception 5: Leaving fields blank if they are not applicable is acceptable.
This approach can cause processing delays. It’s essential to complete all sections that are applicable to your situation, and fields with asterisks (*) require a response.
Misconception 6: The form accepts more than one character per box.
Only one character per box should be entered to ensure clarity and avoid processing delays. This is important for accurate data entry.
Misconception 7: Supplemental forms are unnecessary if the primary application is completed.
In reality, supplemental forms are a crucial part of the application for many providers, as they allow for the inclusion of additional professional IDs, education details, and specialty information that may not fit in the primary application.
Misconception 8: Fields not marked with an asterisk (*) do not need to be filled out.
This is not entirely accurate. While fields marked with an asterisk (*) indicate a response is required, other fields should be filled out as applicable. Leaving them blank could imply they are not applicable, potentially missing crucial information.

Understanding these misconceptions and taking steps to avoid them can lead to a smoother, quicker application process, ensuring that your form is processed efficiently and accurately.

Key takeaways

Filling out the CAQH Provider Application necessitates attention to detail to ensure accurate and complete submissions. The form mandates the use of blue or black ink only and requires information to be printed legibly within the allotted boxes to prevent processing delays.

Applications must be completed with care, adhering to the instruction that only one character is allowed per box. In cases where additional space is needed, applicants are guided to write outside the provided spaces, ensuring clarity and legibility.

Every section relevant to the provider's circumstances must be filled out, emphasizing the importance of completeness in the application process. Sections marked with asterisks (*) are particularly crucial as they signify required responses, without which the application may face delays and necessitate follow-up.

The application utilizes specific "codes" for efficient reporting of information, such as schools attended and languages spoken. These codes are detailed within the application, spanning pages 36 to 43, offering a streamlined approach to filling out the form.

For personal and professional identification purposes, applicants are instructed not to use nicknames or initials unless they form part of the legal name. This requirement underlines the importance of accuracy and consistency in personal information provided.

In the education and training sections, detailed information regarding undergraduate, professional school, and any post-graduate training programs attended is required. This includes dates of attendance, degrees awarded, and comprehensive information about training institutions. The application highlights the necessity of listing all relevant educational and training experiences to avoid gaps and provide a complete professional profile.

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