Streamlining Operations Through Delegated Credentialing

4. Inconsistent standards and disjointed systems can cause delays and raise costs.

Relying on various non-integrated platforms across different departments may result in delays, duplicated work, security concerns, staff burdens, and provider frustration. Credentialing teams often must deal with disconnected systems that slow processes and reduce efficiency. For CMOs and health plan leaders, a disjointed system translates to a fragmented view of provider readiness and limited scalability. For credentialing specialists and CVOs, it means jumping between systems, rekeying data, and trying to enforce consistency without the right tools. 

5. Traditional credentialing takes time that could be saved through delegation.

Traditional, manual credentialing is slow, repetitive, and often fragmented. It can result in duplicated efforts and costly delays. Delegated credentialing, however, may offer a better path forward, allowing a trusted entity — like a hospital or CVO — to take on credentialing responsibilities for a health plan or partner organization. Delegated credentialing supports continuous monitoring, audit-ready documentation, and scalable growth. For CMOs and health plan leaders, continuing with traditional credentialing could mean perpetuating inefficiencies, higher costs, and delayed access to care. For credentialing specialists and CVOs, it’s time-consuming, repetitive work that could be centralized and streamlined. 

What Is Delegated Credentialing?

Delegated credentialing shifts the responsibility for provider credentialing from one healthcare organization (often a health plan) to another (such as a hospital, medical group, or CVO) through a formal agreement. It goes well beyond verifying documents, requiring the delegated entity to evaluate qualifications and make credentialing decisions in alignment with regulatory and accreditation standards.  

Delegated Credentialing Can Be a Win-Win for Health Plans and Provider Organizations

Delegated credentialing can be a more efficient route, helping both health plans and provider organizations reduce costs, streamline processes, and improve satisfaction.  

Benefits for Health Plans

• Time and resource savings 
  Delegated credentialing allows a health plan (the delegating entity) to offload the administrative burden to a hospital, health system, or CVO (the delegated entity). This can save time and reduce overhead by eliminating redundant verifications. 

• Faster network expansion Delegated credentialing can support more rapid onboarding and network participation, enabling plans to expand coverage efficiently and stay competitive. 

• Enhanced provider satisfaction Streamlined enrollment processes may improve contracting relationships and provider retention by reducing wait times and frustration with the process. 

Benefits for Healthcare Organizations

• Expedited provider enrollment and reimbursement 
  Delegated credentialing enables organizations to eliminate weeks from the provider enrollment process. 

• Improved operational efficiency 
  Centralizing credentialing reduces duplication, supports compliance, and enhances data accuracy.  

• Better provider and patient experience 
  Delegated credentialing shortens the delay between hire and service delivery, improving continuity of care.  

The Delegated Credentialing Agreement

Entering into a delegated credentialing agreement means taking on shared responsibility: Both parties must commit to a formal framework that outlines roles, accountability, and compliance expectations. That includes meeting the standards of key regulatory bodies like the NCQA, Utilization Review Accreditation Commission (URAC), Centers for Medicare & Medicaid Services (CMS), and federal and state laws. Delegation agreements can be separate agreements or amendments to existing parent contracts. 

To participate in delegated credentialing, the delegated entity must have a robust, NCQA-compliant credentialing process in place that:  

• Verifies practitioner credentials through a primary source, a recognized source, or a contracted agent of the primary source 

• Has a designated committee in place to review practitioner credentials and make credentialing recommendations 

• Aligns with state requirements  

Standard contracts should include: 

• Roles and responsibilities 

• Reporting requirements 

• Performance evaluations 

• Protected Health Information (PHI) usage terms 

• Remedies for non-compliance 

• Final decision rights of the plan  

Once credentialing responsibilities are established, the delegated entity is authorized to complete credentialing on behalf of the delegating organization. As part of this agreement, the delegate typically submits a monthly provider roster to the delegating entity. This roster is used to associate or disassociate and provide key updates such as status changes, address modifications, and billing information. Upon receipt, any new provider may be designed as "participating" and become eligible for reimbursement. 

Selecting the Right Delegated Entity

When choosing a delegated credentialing partner, delegating entities should consider: 

• NCQA accreditation/certification: Does the delegate have current certification for credentialing functions, or will it work with you to achieve accreditation/certification? 

• Capability and capacity: Does the organization have established systems and processes, trained staff, and technology to scale?  

• Alignment of goals: Can both parties collaborate to support long-term performance? 

• Audit readiness: Is the entity prepared for audits with strong documentation and reporting?