What is delegated credentialing?

Delegated credentialing is an arrangement in which a health plan authorizes a qualified organization to perform specified credentialing functions on the plan’s behalf under a formal delegation agreement. The health plan still maintains oversight and typically audits the delegate’s performance.

Delegated credentialing occurs when a health plan formally authorizes another qualified organization, such as a medical group, health system, or credentialing entity, to perform defined credentialing activities on the payer’s behalf.

The delegation agreement should define which functions are delegated, the standards the delegate must follow, reporting requirements, oversight and audit rights, and performance expectations.

Delegation does not mean the payer has no responsibility. The health plan generally retains oversight and monitors whether the delegated entity performs credentialing according to the agreement.

Delegated credentialing can reduce duplicate work when the organization has a mature credentialing program, but it also creates significant compliance and documentation responsibilities. Not every organization or payer relationship supports delegation.

• Delegated credentialing transfers defined credentialing functions under agreement.
• The scope of delegation must be clearly defined.
• The payer retains oversight responsibility.
• Delegates need strong documentation and audit readiness.
• Delegated credentialing is not available in every payer relationship.

A large medical group has a delegated credentialing agreement with a health plan. The group credentials new physicians using the agreed standards and submits required roster data. The payer periodically audits credentialing files to confirm compliance with the delegation agreement.

• Assuming delegation removes payer oversight.
• Performing activities outside the delegated scope.
• Poor documentation of credentialing decisions.
• Failing to prepare for payer audits.

Explain both sides of delegation: the delegate performs the work, but the payer still oversees performance.