CareFirst Credentialing Service

Become a part of the region’s largest provider network. CareFirst is now one of the most devoted health-care providers in the region. When a Practitioner submits a completed, signed, and certified credentialing application and Consent and Release Form, along with copies of their state license, DEA or CDS, malpractice face sheet, and curriculum vitae, the credentialing process begins. Following that, the Credentialing team will do Primary Source Verification (PSV). In addition, all Practitioners will have their sites reviewed using the Office Site Review Tool, which is available upon request. The Credentialing Committee reviews the application, PSV, and site review outcomes before making a decision.

Why to join Care first?

Become a part of the region’s largest provider network. In Maryland, Washington, D.C., and Northern Virginia, more than 90% of the region’s most dedicated health care providers serve 3.3 million members.

Our Blue Choice and/or Regional Participating Preferred Networks are open to professional providers (RPN). The Council for Affordable Quality Healthcare (CAQH) ProView is the quickest way to apply. All providers in the same practise must engage in the same provider networks to avoid confusion and unanticipated out-of-pocket charges for members.

Initial Credentialing 

A Practitioner is accredited if they:

  • Have a current, unrestricted license to practise their profession 
  • Have a valid Federal Drug Enforcement Administration (DEA) or Controlled Dangerous Substances (CDS) certificate.
  • Demonstrate a level of professional competence that is comparable to that of other network practitioners in their field.
  • Accept to take part in any quality management activities requested by the Quality Management Department of CareFirst CHPDC
  • Provide a professional work history for each position listed, including the start and finish months
  • Provide information about all aspects of education, training, and board certification

How to Apply

Visit our CAQH Universal Credentialing Data source page if you participate with various insurance carriers and would want to submit an application through the Council for Affordable Quality Healthcare (CAQH) online application. Providers willing to apply for our medical and network services can do so online through the CAQH. You must also notify CareFirst in writing, along with your application or CAQH data sheet that you desire to apply to both networks.

  • Supervise employee outcomes by training, assigning, scheduling, coaching, and counseling employees; communicate job expectations; planning, monitoring, and evaluating job contributions; observe policies and procedures
  • Contributes to strategic plans and reviews by providing information; implementing production, productivity, quality, and customer service (provider as customer); addressing problems; and identifying system improvements.
  • Maintains quality assurance goals by monitoring daily operations and resolving quality assurance concerns that require manual review or technical assistance, such as credentialing or provider information. Review systems on a regular basis and make appropriate improvements, including resource/staffing, as needed. Investigates and resolves escalated calls, as well as reviewing and resolving complicated issues that the Quality Assurance team has not been able to handle.
  • Monitors system performance, identifies and resolves operations problems, supervises process improvement, and maintains and enhances departmental operations.

CAQH Proview is Useful

  • Comply with all reporting obligations – You can quickly self-report data is required by health plans, hospitals, and other organizations when you use CAQH’s proview service.
  • Keep your information up to date – You can easily update your information online if it changes.
  • Requirements for re-credentialing must be met – Every three years, CareFirst requires clinicians to complete a re-credentialing process.

Are you ready to take control of your health?

Put the power of good health in your hands with the CareFirst wellness programme, made possible in collaboration with Share care, Inc. Your wellness programme offers a multitude of tools and resources, as well as simple recommendations and insights, targeted to your specific interests and needs—all designed to help you live your healthiest life.

Coordinating Your Care Primary Care Provider in a Patient-Centered Medical Home

You need the best care whether you’re trying to get or stay healthy. Regardless of which CareFirst plan you select, you will have access to programmes and tools that will help you take an active part in your health, treat any health issues, and enjoy a healthier future.

Our Patient-Centered Medical Home (PCMH) initiative is intended to give your primary care provider (PCP) a more comprehensive picture of your health needs, as well as the treatment you receive from other providers. A PCMH Primary Care Physician:

  • Coordinates your health-care requirements
  • When necessary, collaborates with a team to ensure that you receive quality care in the appropriate setting and at the appropriate time.
  • Focuses on overall health and preventing health problems before they occur

Already Using A CAQH?

If you’ve already submitted an application to CAQH, follow these steps:

  • Log in to your CAQH account to double-check your information
  • Give CareFirst permission to view your information
  • Fill out the CAQH Dental Provider Data Sheet and fax it to us

Credentialing Committee

 The Credentialing Committee of Carefirst made up of practitioners who are part of the network. Initial credentialing/re-credentialing decisions are provided to all practitioners in writing. A team of professionals and experienced executives oversee Carefirst Health Plan. We want to pay our providers promptly and accurately, process claims efficiently, and offer our members with high-quality health care services. Carefirst aspires to be one of the best provider-focused managed care organizations in the region.

Perks of Credentialing

Quality relationships between health plans and providers are encouraged by CAQH. When a practitioner completes the online application with CAQH, that practitioner gains access to a single application that may be used for a variety of health plans. This cuts down on the time, money, and difficulties associated with healthcare management. One application takes about 1.5 hours to complete. It may take many hours to complete paper applications for multiple different health plans.

Three Benefits of Using CAQH ProView.

Comply with reporting obligations – You can quickly self-report data required by health plans, hospitals, and other organizations when you use CAQH’s proview service. Only enter your information once if you want to be credentialed with different insurers.

  • Duplicate paperwork should be eliminated or reduced
  • Update your data – If your data changes, you may easily update it online
  • Attestation takes only a few minutes and should be done every 120 days

Choose Us over Others Will Get You Numerous Benefits

  • Over 7,000 doctors to choose from
  • Doctor visits and wellness check-ups
  • Urgent and emergency care
  • A team of people who can help you get the care you need
  • Meals post hospital discharge
  • Benefit coordination
  • Acupuncture for substance abuse

Our Enrollment Is Always Open

There is no deadline for applying for Carefirst, and if you are currently registered, you can switch to CareFirst whenever you choose.

Call the state’s toll-free number at 1-800-977-7388. Monday through Friday | 7:00 a.m.–7:00 p.m.