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Fill Out Your Caqh Provider Application Form

The CAQH Provider Application form is an essential document used by healthcare providers to submit their professional information for credentialing purposes. It helps streamline the process of verifying a provider's qualifications, allowing for easier access to care for patients. Ensuring accuracy in this application is crucial, so start filling it out by clicking the button below.

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Article Structure

The CAQH Provider Application form is an essential tool for healthcare providers seeking to establish their credentials with various health plans and networks. This comprehensive document collects critical information, such as personal identification details, professional affiliations, and educational qualifications. It begins with a series of instructions designed to streamline the application process, emphasizing the importance of accuracy. For example, applicants are instructed to use only a ballpoint pen and to print neatly within the designated boxes. Key sections include personal information, where providers must list their legal name and any aliases, as well as professional IDs—covering everything from DEA registrations to state licenses. Additionally, the form requires details about education and training, including specific schools attended and degrees earned, ensuring that all relevant milestones are captured. Furthermore, applicants must indicate their specialties and certifications, all while adhering to the code lists provided. Missing or incorrect information can lead to unnecessary delays; thus, attention to detail is paramount. Overall, the form serves as a crucial gateway for providers aiming to align with diverse healthcare systems efficiently and effectively, underscoring the importance of initiative in managing one’s professional credentials.

Caqh Provider Application Example

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

3076

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Page 01

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

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

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.

3082

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

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

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

3085

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

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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Get Caqh Provider Application PDF Form

Form Characteristics

Fact Name	Details
Mixed-Case Formatting	The CAQH Provider Application form automatically formats entries in mixed case for readability.
Application Use	Applicants must use only this specific application and its supplemental forms. Using another provider's application is not allowed.
Ink Color Requirement	Applications should be completed using a blue or black ink ball-point pen. Pencils or felt-tip pens are prohibited.
Required Fields	Fields marked with an asterisk (*) require a response. Incomplete responses may lead to delays in processing.
Personal Information	Personal details required include your legal name, date of birth, and Social Security Number (except for those with a Foreign National Id).
Professional IDs	Applicants must provide details regarding all professional IDs, including federal DEA numbers and any relevant state licenses.
Education Section	The application requires information about undergraduate and professional schools attended, including degrees awarded.
Certification Query	Applicants must indicate their status with Medicare and Medicaid, including numbers if applicable.

Guidelines on Utilizing Caqh Provider Application

The following steps outline the process for completing the CAQH Provider Application form. Ensure all required information is accurate and complete to avoid delays in processing.

Access the CAQH Provider Application form.
Use a blue or black ink ball-point pen. Avoid using a pencil or felt-tip pen.
Print your responses legibly within the designated boxes and follow the example formatting carefully.
Do not enter more than one character per box. If necessary, continue your response outside of the boxes provided.
Complete all required sections. Fields marked with an asterisk (*) must have a response.
Refer to the code lists on pages 36 to 43 when entering codes for schools or languages.
For personal information, enter your legal name without using nicknames. Provide details about any other names you have used.
Include your gender, date of birth, and other identification numbers as required.
Provide your home address, telephone number, and preferred method of contact.
For each professional ID, provide the necessary licenses, DEA numbers, and any relevant certification details.
For education and training, fill in the details of the undergraduate and professional schools attended, including start and end dates, as well as degrees awarded.
List all training programs you have attended, providing full details of each institution.
For specialty information, select your primary and secondary specialties from the provided codes, and provide certification details.

What You Should Know About This Form

What is the CAQH Provider Application form?

The CAQH Provider Application form is an essential document for healthcare providers seeking to streamline their credentialing process. The form gathers detailed information about the provider’s personal, educational, and professional background. By submitting this application, providers can easily share their credentials with various health insurance organizations and networks, facilitating quicker enrollment and reducing administrative tasks.

What are the common mistakes to avoid when filling out the CAQH Provider Application form?

It’s crucial to follow specific guidelines to prevent processing delays. Ensure you complete the application using a blue or black ball-point pen, avoiding pencils or felt-tip pens. Print clearly and limit each character input to the designated boxes. Check that all applicable sections are filled out completely, noting that fields marked with an asterisk (*) are required for submission. Additionally, refrain from using nicknames or initials unless they're part of your legal name to ensure accuracy and compliance.

How can I ensure my application is processed smoothly?

To enhance your application’s processing efficiency, carefully review all instructions before submitting. Start by utilizing only the specified application and supplemental forms. complete each section relevant to your profession. Be diligent in providing all required responses and verify that information, such as Professional IDs and licenses, is correct and up to date. If you encounter any uncertainties, use the help desk as a resource for assistance, which can mitigate potential delays.

What information is needed for the Personal Information and Professional IDs section?

This section requires various personal details, including your full legal name, gender, date of birth, and contact information. It also includes Professional IDs such as your Social Security Number (SSN) or Foreign National Identification Number (FNIN), and relevant licensing information. Additionally, you must provide data about your Medicare and Medicaid participation, if applicable. It's vital to enter the correct codes related to your provider type and ensure that every field requiring a response is filled to avoid any processing issues.

Common mistakes

Completing the CAQH Provider Application form is a crucial step for healthcare providers seeking credentialing. However, many individuals make mistakes that can cause delays in processing. Awareness of these common pitfalls can greatly enhance the accuracy and efficiency of the application process.

One frequent mistake is using the wrong type of pen. Applicants often neglect the instruction to use only a blue or black ballpoint pen, leading to issues with legibility and processing. Using a pencil or felt-tip pen can result in forms that are not accepted, causing further delays.

Another common error occurs when applicants do not print legibly. Submitting an application filled with unclear handwriting can lead to misunderstandings or omissions. Following the provided examples closely helps to ensure that the information is read correctly.

Inadequate attention to required fields can also hinder progress. Many candidates leave fields marked with an asterisk (*) blank, which indicates mandatory responses. This absence forces applicants to revisit submissions, wasting valuable time.

The use of nicknames or initials instead of full legal names is another misstep. The application requires full legal names without abbreviations, and deviating from this can lead to discrepancies that affect credentialing outcomes.

Many applicants fail to check for errors in the information they provide. Simple mistakes, such as entering incorrect social security numbers or misspelling names, can have significant consequences. Careful review prior to submission can prevent these errors from derailing the application.

Providing incomplete educational information is also problematic. Applicants often forget to list all institutions attended or may omit graduation dates. Each educational institution reported should be complete with accurate details to ensure compliance with credentialing standards.

Overlooking the requirement to report all professional licenses can further complicate the application process. It is essential to include any state-specific or specialized certifications that may apply, as failing to do so can create gaps in an applicant's professional history.

Failure to update previous names, if applicable, may create further confusion. Applicants must disclose all other names used, along with respective dates, to maintain an accurate record. Neglecting this could lead to complications when verifying qualifications.

Lastly, another frequent oversight involves neglecting the additional forms required for comprehensive information. Many applicants do not adhere to instructions that indicate when to use supplemental forms for further details. Missing these forms can result in incomplete submissions.

Understanding these common mistakes can be advantageous for healthcare providers filling out the CAQH Provider Application form. By addressing these issues proactively, applicants can facilitate a smoother processing experience, paving the way toward successful credentialing.

Documents used along the form

The CAQH Provider Application form is a vital document used by healthcare providers seeking to be credentialed by various insurance companies and health plans. Along with the primary application form, there are several other important documents that may be needed to support the application process. Each of these forms plays a significant role in providing comprehensive information about the provider's qualifications, background, and practice. Below is a list of additional forms and documents commonly used in conjunction with the CAQH application.

Educational Verification Form: This document confirms a provider's educational background, including undergraduate and professional degrees. It typically requires submission from the institutions attended to ensure authenticity.
Training Verification Form: This form details a provider's residency, internship, and fellowship training experiences. Verification from the relevant institutions is often required to corroborate the training received.
State Licensure Verification: This document provides proof of a provider's current licensure status in the state where they intend to practice. It assists in confirming that the provider is legally allowed to operate within that jurisdiction.
National Provider Identifier (NPI) Confirmation: The NPI is a unique identification number required for healthcare providers. This confirmation verifies the provider's NPI, ensuring that it is active and accurate.
Malpractice Insurance Certificate: Often necessary for credentialing, this certificate shows that the provider has professional liability insurance in place, offering protection against potential malpractice claims.
Curriculum Vitae (CV): A comprehensive CV outlines a provider's professional history, including education, training, certifications, and work experience, thus providing an overview of their qualifications.
Disclosure of Ownership Form: This form discloses any ownership interests that a provider may have in healthcare entities. Transparency in ownership helps avoid conflicts of interest and promotes accountability.
References and Recommendation Letters: Some credentialing processes require letters from colleagues or mentors that speak to the provider's skills, qualifications, and professional conduct.
DEPARTMENTS FOCUS DOCUMENT: Certain specialty providers may need to include a document focusing on the specific areas they are recognized in, helping to highlight their expertise.
Criminal Background Check Authorization Form: This form authorizes a background check as part of the credentialing process, ensuring that the provider’s history is clear of disqualifying events.

Incorporating these forms and documents in conjunction with the CAQH Provider Application can help streamline the credentialing process. Gathering and submitting complete and accurate information may reduce delays and lead to a smoother approval process, allowing healthcare providers to focus on their vital work in serving patients.

Similar forms

Credentialing Application: Much like the CAQH Provider Application, this document collects personal and professional information for healthcare providers. Both require detailed educational history and licensing details.
Medicare Enrollment Application: The Medicare application form shares similar requirements by requesting provider identifiers, contact information, and service details needed for enrollment.
State Medical License Application: Both forms require disclosure of personal information, training history, and professional credentials to ensure compliance with state regulations.
CAQH Provider Data Source: This document serves a similar purpose by aggregating provider information for credentialing and requires many of the same data points regarding practice and background.
Credentialing Verification Organization (CVO) Application: Like the CAQH form, this application gathers comprehensive credentials to streamline the credentialing process for healthcare providers.
Employment Application for Healthcare Professionals: This document also requests background, training, and professional details, mirroring the CAQH focus on verifying qualifications.
Provider Enrollment Application for Medicaid: Similar to CAQH, this application includes sections for personal demographics and professional qualifications critical for Medicaid enrollment.
Board Certification Application: This application parallels the CAQH form in that it requests verification of education, residency, and specialty training, which are essential for board certification consideration.
National Provider Identifier (NPI) Application: Both forms necessitate personal, practice location, and professional identifiers to ensure accurate provider profiling in the national system.
Hospital Privileges Application: This document, like the CAQH Provider Application, requests extensive verification of credentials, training, and professional history for granting hospital privileges.

Dos and Don'ts

When filling out the CAQH Provider Application form, follow these guidelines to ensure a smooth and efficient process.

Read all instructions carefully before starting the application to avoid any mistakes.
Complete only this application and its supplemental forms. Never use another provider’s application.
Use a blue or black ink ball-point pen. Pencils or felt-tip pens are not acceptable.
Print legibly and use the boxes provided properly. Avoid exceeding one character per box.
Ensure all applicable sections are completed thoroughly, including any fields marked with an asterisk (*).
For certain fields, use the “codes” provided to report information accurately. Code lists are available in the application.

In contrast, avoid the following:

Do not use nicknames or initials unless they are part of your legal name.
Do not leave optional fields blank if those fields are required by the application.
Do not enter National Provider Identification (NPI) numbers in the spaces designated for other identification numbers.
Avoid entering foreign national identification numbers unless you do not have a Social Security Number (SSN).
Do not ignore gaps in your employment or training. Provide an explanation if necessary.
Do not assume that incomplete or incorrectly filled fields will be accepted; all responses matter.

Misconceptions

Misconceptions about the CAQH Provider Application form can lead to delays or errors during the application process. Understanding these misconceptions is vital for a smooth application experience.

Only Medical Professionals Need to Complete the CAQH Application. Many believe that only physicians must fill out this application. However, it is essential for various healthcare providers, including nurse practitioners and physician assistants, to complete the CAQH Provider Application.
You Can Use a Penciled Application. There is a common belief that using a pencil or felt-tip pen is acceptable for filling out the application. In reality, the instructions explicitly state that only blue or black ink ball-point pens should be used to avoid processing complications.
All Fields Must Be Completed Regardless of Relevance. Some applicants think that they must fill in every field on the form, even those not applicable to their situation. The form indicates that leaving non-applicable fields blank is permissible, provided the required fields are addressed.
Submitting a Different Provider's Application is Acceptable. Many individuals mistakenly believe they can adapt another provider's application for their use. The instructions clearly emphasize that each provider must submit their own application to ensure accurate data and compliance.
It’s Okay to Use Nicknames in the Name Fields. Some applicants consider using nicknames or initials as part of their legal names acceptable. It is important to enter full names as they appear in formal records to avoid issues with identity verification.

Key takeaways

Read the Instructions Carefully: Before diving into the application, take the time to go through the instructions thoroughly to ensure you understand what is required.
Use the Correct Tools: Only complete the application using a blue or black ballpoint pen. Avoid using pencils or felt-tip pens.
Print Clearly: Your responses should be legible. Fill in the boxes as specified and do not exceed one character per box—if needed, use outside space for longer entries.
Complete All Relevant Sections: It's essential to fill out all applicable sections of the application. Fields with asterisks indicate required information.
Provide Accurate Codes: Familiarize yourself with the code lists provided in the application to correctly report your information, including schools and languages.
Check Your Personal Information: Ensure your name, address, and identification details are correct. Avoid using nicknames unless they are part of your legal name.
Use Current Information: Confirm all details, such as professional licenses and certifications, are up to date to avoid delays in processing.
Identify Your Provider Type: Select the appropriate code for your provider type and clearly indicate if you primarily practice in an inpatient setting.
Follow Up on Your Application: Watch for communication from CAQH regarding your application. Ensure your preferred contact method is correctly indicated.
Be Prepared for Additional Documentation: If you have multiple licenses or professional IDs, be ready to provide supplemental forms as needed.

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