Credentialing 101: How to Set Up Your Process for Success
A reliable credentialing system provides essential clarity, consistency, and protection for the organization.
Many ASCs struggle to build a predictable credentialing process, adding unnecessary risk during onboarding or reappointment cycles. A reliable credentialing system provides essential clarity, consistency, and protection for the organization. Administrators quickly discover that credentialing is more complex than collecting documents; it requires structure, communication, and ongoing oversight to reduce compliance risk and strengthen trust.
To establish a strong foundation, leaders must first clarify the core definitions at play. Credentialing is the systematic process of verifying a provider's qualifications to confirm they meet the standards required to practice safely. Privileging confirms that a provider is approved to perform specific procedures at the ASC.
Building a strong foundation involves understanding these components and creating systems that keep information current throughout the year. An organized structure ensures that administrators can quickly assess completeness, identify missing items, and prepare effectively for governing body review.
Here is the framework for establishing a reliable, compliant credentialing program.
Start With a Clear Structure
A well-defined credentialing structure is built upon regulatory and governance requirements. The foundational step is ensuring your process adheres strictly to accreditation standards, Department of Health (DOH) mandates, and your facility's Medical Staff Bylaws. From this compliant baseline, administrators should implement organized folders, standardized templates, and a clear checklist for each provider. The system must support:
- Easy access to information
- Logical organization
- Clear expectations for required documents
- Defined verification steps
Know What Belongs in Every File
Each provider’s file must include a comprehensive set of documents that are complete, consistent, and easy to review in their entirety. It is critical to ground these requirements in specific accrediting standards. For example, the Accreditation Association for Ambulatory Health Care (AAAHC) requires specific documentation to demonstrate a provider's qualifications and ongoing competence. Other accrediting bodies hold similar high standards, though their specific requirements may vary slightly.
- A compliant ASC credentialing file generally includes:
- Current licensure and relevant certifications
- Professional liability insurance
- Education, training, and work history records
- Privilege request forms
- Health records, background checks, and peer references
- Verification documentation
Establish Strong Verification Practices
Verification confirms that education and licensure of an individual. It extends beyond confirmation of required to standards to confirm that the provider is trained and qualified to provide the requested procedures and/or services to a patient to ensure quality and safety of patient care. Every verification must be documented and stored in the provider’s file. Key steps include:
Primary source verification for licensure. "Primary source" refers to the original source of a specific credential, such as a medical board or educational institution, rather than a secondary document provided by the applicant. All primary sources should be verified for current active licensure to practice as well as prescribe controlled substances, as applicable.
Confirmation of all training and education for the provider as well as any required training for equipment, new techniques, and/or procedures that are added to the facility.
Verification of board certification and ensuring compliance with the requirements of the Medical Staff Bylaws.
Check for Sanctions and Restrictions — Automatically and Consistently
Verifying sanctions and restrictions is one of the most critical steps in protecting an ASC. In a manual workflow, this often means logging into multiple databases, tracking results in spreadsheets, and repeating the process periodically—leaving room for oversight, inconsistent timing, or outdated information.
An electronic credentialing system centralizes and automates these checks, ensuring providers are screened at the time of onboarding and continuously monitored afterward. This reduces administrative burden, strengthens compliance, and minimizes the risk of missed red flags.
ASCs should ensure they are screening providers against all relevant sources, including:
- OIG Exclusions (LEIE – List of Excluded Individuals and Entities)
- SAM.gov (System for Award Management)
- State medical licensure board disciplinary actions
- NPDB (National Practitioner Data Bank) reports and adverse actions
- DEA registration and restrictions
- Medicare/Medicaid sanctions
- State Medicaid exclusion lists
- Sex offender registries (where applicable)
- OFAC (Office of Foreign Assets Control) sanctions lists
Electronic credentialing platforms automate the retrieval, logging, and re-checking of these databases, creating a consistent, defensible process. Instead of relying on manual lookups or reminders, ASCs gain real-time visibility into a provider’s status and immediate alerts if anything changes.
Track Expirations Proactively
Licenses, certifications, and liability insurance have specific expiration dates, and missing these can delay scheduling or jeopardize compliance. Proactive tracking prevents last-minute challenges and ensures providers remain eligible to practice. Successful programs rely on:
- Automated reminders
- Monthly file reviews
- Clear responsibilities for follow-up
- A visible tracking system
Clarify the Privileging Process
The goal of privileging is to align privileges with verified qualifications so the governing body can make informed decisions. This process must be conducted in strict accordance with Medical Staff Bylaws, applicable regulations, state laws, and facility policies. Administrators help facilitate this critical workflow by:
Provide a Clear, Written Privilege Matrix
Publish a specialty-specific privilege list showing:
Core vs. optional privileges
Required documents for each privilege
Case-volume or competency requirements
Use Plain-Language Explanations
Many providers aren’t familiar with the nuances between:
Privileges vs. credentialing
Temporary vs. full privileges
Core vs. special privileges
Providing simple definitions upfront avoids confusion.
Centralize All Requirements in One Place
Avoid scattering requirements across emails, PDFs, and internal folders.
Explain Why Each Requirement Exists
Providers comply more easily when they understand the “why”
Case logs → verify ongoing competency
Malpractice claims history → assess risk
CME certificates → support specialty-based requirements
Context lowers friction.
Communicate Timelines and Review Cycles
Clarify What Triggers Additional Review
Let providers know upfront if special privileges require:
Case volume thresholds
Proctoring
Demonstration of competency
Additional peer references
This avoids surprises later.
Make Privilege Renewal Expectations Clear
Providers should know:
How often reappointment occurs (annual/bi-annual)
What documents must be updated
If case logs are required annually
When the ASC sends reminders
Explain the Difference Between Privileges and Scheduling
Admins often must clarify:
"Privileges approved" does not automatically mean they can be scheduled unless credentialing is fully complete.
OR staff need the privilege letter in hand before room assignment.
Send Automated Reminders Before Privilege Expiration
90-day notice
60-day notice
30-day notice
Providers appreciate proactive communication.
Communicate Early and Often — And Let Your System Do the Heavy Lifting
Credentialing involves many moving parts, and manual processes often create unnecessary delays simply because communication breaks down. Paper checklists, scattered emails, and ad-hoc reminders leave too much room for error.
An electronic credentialing platform dramatically improves clarity and momentum by centralizing communication and automating updates. Instead of chasing information, both administrators and providers know exactly what to expect and when. With a digital system, ASCs can strengthen communication by:
- Providing dynamic, automated checklists that update in real time as requirements are completed
- Delivering clear, standardized instructions directly through the platform to reduce back-and-forth emails
- Setting and tracking turnaround expectations with built-in timelines, reminders, and automated alerts
- Keeping providers informed automatically with status updates and notifications as their file progresses
Manual processes rely on people remembering to follow up.
Electronic systems ensure nothing gets missed. This shift from reactive communication to proactive, automated transparency is one of the most impactful ways ASCs can streamline credentialing and reduce frustration for everyone involved.
Maintain Predictability Through Oversight
Credentialing is not a one-time event; ongoing oversight reduces the risk of gaps and helps the ASC remain prepared for surveys. Administrators must support the governing body by ensuring files are updated, organized, and ready for review. Successful programs maintain:
- Monthly audits
- Up-to-date checklists
- Clear follow-up routines
- Consistent communication with providers
A predictable, well-organized credentialing process supports compliance, safety, and operational stability. Administrators who invest time into creating a reliable structure experience fewer disruptions and greater confidence during surveys, resulting in a stronger, more stable ASC environment.