What is a credentialing audit?

A credentialing audit reviews whether credentialing files and processes follow required policies, payer agreements, delegation standards, or accreditation requirements.

Audits may be internal or performed by a payer, accreditation organization, or other oversight body. Review can include application completeness, primary-source verification, sanction checks, timeliness, committee documentation, recredentialing records, and compliance with written policies. Strong audit readiness comes from consistent day-to-day documentation.

• Audits evaluate credentialing process quality and compliance.
• Documentation and verification evidence are central.
• Delegated arrangements often involve payer audits.
• Policies should match actual practice.

A health plan audits a delegated group and requests a sample of provider files showing complete applications, verification evidence, sanction checks, and approval records.

• Preparing files only after audit notice.
• Missing verification evidence.
• Policies that do not match actual workflow.

Focus on what the auditor verifies: completeness, source verification, timing, and documented decisions.