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5 Things You Need to Know Now About Provider Data, CAQH, and CAQH Enrollment and Integration

March 20, 2023
March 20, 2023

According to The Hill, “The country’s health care tab came in at a whopping $3.3 trillion in 2016 — 17.9 percent of GDP. We spend $10,348 per person, per year, nearly twice the average of other modern economies. Yet despite the fortune spent, we still don’t have better health outcomes.”

While the politicians debate the expenses and who should pay the tab, the healthcare industry is taking action with the goal of reducing healthcare costs. One such effort is being driven by the Council for Affordable Quality Healthcare (CAQH), a non-profit alliance of health plans and related associations that has banded together around the shared goal of streamlining the business of healthcare.

1. According to the CAQH, “The ongoing need to reduce healthcare costs— especially administrative expenses—while concurrently increasing information accuracy is at the heart of CAQH activities. In concert with a wide range of healthcare stakeholders, CAQH develops and implements shared, industry-wide initiatives to eliminate long-term business inefficiencies, producing meaningful, concrete benefits for healthcare providers, health plans and patients.” CAQH projects that their initiatives will fundamentally change the direction of healthcare and redefine how the industry does business.

2. CAQH believes that provider data drives the most fundamental processes in the healthcare system, and understands that although the industry spends more than $2 billion annually* to maintain provider data, inaccuracies and inefficiencies are still pervasive. In the Industry Roadmap for Provider Data, CAQH identifies several key issues that contribute to the persistence of provider data inaccuracies. These include:


  • Limited authoritative sources:
    • – For many data elements, no sufficiently accurate source exists. In some cases, multiple sources exist for a single data element – leading to conflict – and in others, sources advertised as authoritative have accuracy issues. Where there are no authoritative sources, users may be forced to interpret data in an inconsistent fashion.
  • Variation of requirements and standards:
    • – Variations in the format, exchange, content and understanding of the uses of provider data lead to unreliable data.
  • Frequent data changes:
    • – Providers are being subject to redundant and conflicting requests for data. These requests may be in different formats, on different schedules, and via different methods. The demand for real-time provider data has increased, but new procedures, tools and business processes to support this faster pace have not materialized.
  • Lack of consistent provider engagement:
    • – Providers themselves have not been actively involved in provider data discussions and are thus not adequately engaged in efforts to ensure correct data is collected. As the burdens to produce data increase, they are turning to external resources for support, further complicating the compilation of accurate data.

...although the industry spends more than $2 billion annually* to maintain provider data, inaccuracies and inefficiencies are still pervasive.

3. Based on its analysis of provider data issues plaguing the industry, CAQH convened the Provider Data Action Alliance (Alliance), a cross-industry group of leaders representing health plans, hospitals and health systems, government, regulators and health information exchanges, to develop the Industry Roadmap for Provider Data. The Roadmap presents a “collaborative approach for finally addressing the provider data challenge through industry alignment on a core set of principles, a vision for a healthy provider data ecosystem and recommendations for key steps forward.”

The core principles identified to guide the development of an industry solution state:


  • The time and attention of providers must not be wasted.
  • The solution must be flexible and adaptable.
  • The solution must be pragmatic and focused on near-term business realities.
  • The solution should be industry-governed and standards-based.

The vision for a healthy provider data ecosystem centers on four critical components:

  • Governance
  • Defined set of “fundamental” provider data elements
  • A centralized authoritative solution
  • An incremental approach

4. CAQH’s vision for a centralized authoritative solution is coming to fruition with the development of solutions that authenticate the accuracy and completeness of provider information to support credentialing decisions. One such solution is CAQH ProView®. A solution described by CAQH as: “A web-based solution used by more than 1.4 million providers to self-report and share a wide range of demographic and professional information with more than 900 participating health plans, hospitals, health systems and provider groups. This data is then used for credentialing, network directories, claims administration and more.”

5. At this point in time, participation in CAQH initiatives, including CAQH ProView is voluntary. But some health plans and other healthcare organizations are beginning to request that their network providers use CAQH ProView for new recredentialing events. We expect this trend to grow, and when it does, your medical group practice needs to be ready.


Preparing for CAQH Enrollment

Because provider data is involved in so many processes, the core set of “fundamental” provider data elements that you need to collect for CAQH Enrollment is vast. A sample of the information needed to begin CAQH Enrollment is listed in the ProView Provider Quick Reference Guide and includes:


  • CAQH-supplied Provider ID Number
  • Previously completed credentialing application if available (for reference)
  • List of all previous and current practice locations
  • Identification numbers, such as Social Security Number, National Provider Identifier (NPI), DEA, UPIN, and License Number
  • Electronic (scanned) copies of the provider’s:
    • Curriculum Vitae
    • Medical License
    • DEA Certificate
    • CDS Certificate
    • IRS Form W-9
    • Malpractice Insurance Face Sheet
    • Summary of any pending or settled malpractice cases
    • Any other required supporting documents

Many of the medical group practices we work with believe that all this required data is somewhere, but that somewhere is usually not ‘right at their fingertips’. Just over half of the provider enrollment professionals we surveyed use some type of software solution to help automate their enrollment processes. The rest continue to manage enrollment by keeping data in paper files, Excel spreadsheets, and Access or homegrown databases. If you don’t have a single source of truth to collate and track your provider data, you’ll struggle with CAQH integration.

Putting technology to work for you is the key to successful CAQH integration. Solutions like Enroll can greatly simplify the enrollment process. Enroll offers an easy approach to collecting accurate information on behalf of your providers and sharing it with CAQH and every health plan that needs access to it. With Enroll you can dramatically accelerate the provider enrollment process, shrink enrollment timelines (by 65 percent or more), slash costs (by 50 percent or more), and reduce aging receivables (by as much as 97 percent)


Technology is the Key to CAQH Integration

For successful CAQH integration, seek a solution that checks the following boxes:

Features a comprehensive database of U.S. physicians, nurse practitioners, physician assistants, allied health professionals, and registered nurses that includes data elements like demographics, addresses, specialties, licenses, affiliations, education, and expertise details and is constantly updated.

Enables intuitive provider enrollment with functionality that allows providers to auto populate required forms with real-time validated data from sources like AMA and CAQH.

Features a large content database of thousands of pieces of instantly deployable content to help you manage all of your processes including; workflows for initial and recredentialing, expirables management, surveys, API, HL7 imports/exports, dashboards, and online applications.

Has the most up-to-date, standardized industry data tables that put all the data you need within easy reach including data from: payers, hospitals, malpractice, insurance, taxonomy, Universities, States, DEA schedules, zip codes, FOL, diagnosis, and ICD10 codes.

Offers a one-stop shop for providers and reviewers to share data.

If you’re struggling with CAQH integration, VerityStream can help you get your own house in order. Ultimately, a consistent process for collecting provider data will improve your data quality, fill in missing gaps, and benefit your organization and the healthcare industry as a whole. Request a free CAQH check-up with a VerityStream representative today.