CCPP Module 7, Section 5: Maintaining Active Credentials and Renewals
Module 7: Credentialing, Privileging, and Malpractice Setup

Section 7.5: Maintaining Active Credentials and Renewals

An exploration of the ongoing responsibilities of a credentialed provider, including the re-credentialing process, CAQH re-attestation, and the importance of meticulous record-keeping for all licenses and certifications.

SECTION 7.5

Maintaining Active Credentials and Renewals

From Static Achievement to Dynamic Stewardship: The Art of Professional Readiness.

7.5.1 The “Why”: The Perishable Nature of Professional Trust

You have successfully summited the twin peaks of credentialing and privileging. You have been vetted by payers and approved by the medical staff. You are an in-network, privileged provider with a defined scope of practice. There is a powerful, and dangerous, temptation to view this as a finished task—a one-time administrative mountain that, once climbed, is conquered forever. This perspective is a critical error. The credentials and privileges you have worked so hard to obtain are not permanent monuments; they are perishable assets. They represent a grant of trust from payers, health systems, and ultimately, patients—and this trust is subject to regular, mandatory renewal.

The healthcare environment is not static. Standards of care evolve, new regulations are passed, and providers’ own circumstances change. A license that was valid yesterday may expire tomorrow. A provider with a clean record today may face a board complaint next month. Because of this constant flux, the entire credentialing and privileging ecosystem is built on a foundation of ongoing verification, not a one-time check. Every accrediting body, from The Joint Commission to the National Committee for Quality Assurance (NCQA), mandates that healthcare organizations re-verify the qualifications of their providers on a regular, cyclical basis. This is not a bureaucratic choice; it is a fundamental requirement for maintaining accreditation and ensuring patient safety.

Therefore, you must undergo a profound mental shift. You must move from viewing credentialing as a project to be completed to viewing it as a continuous professional process to be managed. It is a form of professional stewardship. Your responsibility is not just to perform your clinical duties competently, but also to proactively manage and maintain the administrative architecture that makes your practice possible. Failing to do so has severe consequences: your billing privileges can be suspended, your clinical privileges can be revoked, and your ability to care for patients can be brought to an abrupt halt, all because of a missed deadline or an outdated document. This section is your masterclass in creating a bulletproof system for managing this ongoing responsibility, transforming it from a source of anxiety into a routine, predictable, and fail-safe component of your professional life.

Pharmacist Analogy: Maintaining Your Commercial Pilot’s License & Type Rating

In the previous section, we compared privileging to a pilot earning a “type rating”—the specific credential that allows them to fly a particular aircraft, like a Boeing 777. Earning that rating is an intense, one-time achievement involving months of study and simulator training. This is your initial privileging process. But does the airline and the FAA then say, “Congratulations, you are now a 777 pilot for life, have fun”? Absolutely not.

A pilot’s authority to fly is in a constant state of renewal. Their professional life is governed by a rigorous, non-negotiable schedule of maintenance and re-verification. This is the direct parallel to maintaining your clinical credentials.

Consider the ongoing requirements for that 777 captain:

  • Recurrent Training (Your CE and Re-Certification): Every year, that pilot must go back to the training center for several days of “recurrent” training, practicing emergency procedures in the simulator and being tested on aircraft systems and regulations. This is your continuing education and board re-certification. It’s not optional; it’s a condition of keeping the rating.
  • Flight Review (Your CAQH Re-Attestation): Every 24 months, a pilot must complete a flight review with an instructor, who re-verifies their basic flying skills. Your quarterly CAQH re-attestation is a more frequent, administrative version of this—a regular check-in to confirm your “flight plan” of professional data is still accurate.
  • Medical Certificate (Your License Renewal): A pilot’s license is useless without a current medical certificate, which must be renewed every 6 or 12 months. This is your state license renewal. Letting it lapse grounds you instantly.
  • Proficiency Checks (Your Re-Privileging & OPPE): The airline continuously monitors the pilot’s performance through data analysis (the OPPE). Periodically, an FAA examiner or a check airman will ride in the cockpit to observe their performance on a real flight (the FPPE). Based on this ongoing review, the airline formally re-privileges them to continue acting as a captain.

A pilot does not see these activities as burdens; they see them as the fundamental, non-negotiable process of being a professional pilot. They are built into the rhythm of their career. They have systems—logbooks, calendars, and checklists—to manage every deadline with military precision, because a missed deadline doesn’t result in a late fee; it results in being grounded. As a clinical pharmacist, you must adopt the same mindset and build the same meticulous systems. This section will teach you how to be the “captain” of your own professional credentials.

7.5.2 The Digital Heartbeat: Mastering the CAQH Re-Attestation Cycle

Your CAQH ProView® profile is the single most important data repository in your professional life. It is the central hub that feeds information to nearly every payer and health system you work with. Its data integrity is paramount. Because a provider’s information can change at any time—a new home address, a renewed license, a new board certification, a new job—CAQH and the payers who rely on it require you to proactively review and reaffirm the accuracy of your information on a regular basis. This process is called re-attestation.

The re-attestation cycle is typically every 120 days (four months). Approximately 30 days before your deadline, CAQH will begin sending automated email reminders to the address on file. These emails are not spam; they are the critical heartbeat of your credentialing maintenance. Ignoring them is one of the fastest ways to cause a cascade of administrative problems.

The “Why” Behind the 120-Day Cycle

The 120-day cycle is a standard set by the National Committee for Quality Assurance (NCQA), a leading accrediting body for health plans. NCQA standards require health plans to verify their provider data on a regular basis to ensure their provider directories are accurate for patients and that they have the most current information for quality monitoring. By mandating that providers re-attest to their data every four months, CAQH ensures that the information being pulled by health plans is never more than a few months old, satisfying these accreditation requirements. When you re-attest, you are essentially providing a fresh, legally-signed “snapshot” of your professional data that payers can rely on for the next 120 days.

Masterclass Walkthrough: The Perfect Re-Attestation Process

A perfect re-attestation is not simply logging in and clicking the “attest” button. That is a dangerous shortcut that leads to stale data and future problems. A professional, defensive re-attestation is a methodical, section-by-section review. Allocate 15-20 minutes in your calendar for this task every four months.

The Pharmacist’s Quarterly CAQH Review Checklist

When you receive your re-attestation reminder, log in to your ProView profile and use this checklist to conduct a thorough review before you click “attest.”

CAQH Section Review Question Checklist
Personal Information
  • Has my legal name changed?
  • Is my home address still current? (Crucial for receiving correspondence).
  • Are my contact phone number and email address correct?
Practice Information
  • Are all my practice locations listed correctly?
  • Have any office phone or fax numbers changed?
  • Are the office hours accurate?
Licenses
  • Have I renewed any of my state pharmacist licenses since my last attestation?
  • If so, have I updated the expiration date and uploaded a PDF of the new license certificate?
DEA / CDS Certificates
  • Have I renewed my DEA or state controlled substance registration?
  • If so, is the new expiration date entered and the new certificate uploaded?
Education & Training This section rarely changes, but give it a quick review for accuracy.
Board Certifications
  • Have I achieved a new board certification (e.g., just passed the BCPS exam)?
  • Have I completed my re-certification for an existing credential? If so, update the expiration date and upload the new certificate.
Work History
  • Is my current employment information correct?
  • If I have left a job, have I entered the correct end date (MM/YYYY) and ensured there are no unexplained gaps?
Malpractice Insurance
  • Has my malpractice policy renewed?
  • If so, I must update the policy number (if changed), the effective dates, and the expiration date. I must also upload the new declarations page.
Disclosure Questions
  • Has anything occurred since my last attestation that would require me to change a “no” answer to a “yes”? (e.g., a new lawsuit, a board investigation). This requires absolute honesty.
The Consequence of a Lapsed Attestation

When your re-attestation deadline passes, your profile status in the CAQH system automatically changes from “Attested” or “Complete” to “Expired.” When a payer attempts to access your profile for re-credentialing or even a routine data check, they will be blocked and will see the “Expired” status. This triggers an immediate red flag in their system. Their credentialing department will send you a notice, often with a tight deadline, demanding that you re-attest. If you fail to do so promptly, they will begin the process of terminating your network participation for “failure to maintain current credentialing information.” It is a completely avoidable problem that can have devastating impacts on your billing and practice.

7.5.3 The Cyclical Review: Payer Re-Credentialing and Health System Re-Privileging

While your CAQH re-attestation is a self-directed quarterly task, re-credentialing and re-privileging are formal processes initiated by the external organizations you work with. These are the formal audits of your professional standing that occur every two to three years.

Payer Re-Credentialing: The Two-Year Check-Up

Most payers, following NCQA guidelines, will re-credential their network providers at least every 36 months (3 years), with many of the larger plans opting for a more frequent 24-month cycle. The primary purpose is to ensure you still meet their network requirements and to re-verify any credentials that may have changed or expired.

The Process:

  1. Notification: You (or your designated credentialing contact) will receive a formal notification from the payer, typically 90-180 days before your current credentialing expires, informing you that it is time for re-credentialing.
  2. CAQH is Key: The notification will almost always instruct you to ensure your CAQH profile is up-to-date and recently attested, and that you have granted them authorization to access it. If your CAQH profile is in perfect shape, this may be the only action you need to take.
  3. Supplemental Forms: Some payers, especially state Medicaid programs, may require you to complete a shorter, supplemental re-credentialing form to capture any state-specific information.
  4. Background Re-Verification: The payer’s credentialing department will then pull your CAQH data and re-run their background checks. They will perform primary source verification on your license (to ensure it’s still active and unrestricted), check the NPDB for any new reports, and confirm your malpractice coverage is still in force.
  5. Approval: Assuming no red flags are found, your file will be approved, and your network participation will be extended for another 2-3 year period. You will receive a formal letter confirming this.

Health System Re-Privileging: The OPPE-Driven Performance Review

Re-privileging, which typically occurs every 24 months to comply with The Joint Commission standards, is a more in-depth and performance-focused process than payer re-credentialing. While it includes a re-verification of your core credentials (license, certifications, etc.), its main focus is on evaluating your actual clinical practice within the institution over the past two years. This is done through a process called Ongoing Professional Practice Evaluation (OPPE).

OPPE is a data-driven process where the health system collects and analyzes information to assess your clinical competence and professional conduct. For a clinical pharmacist, this is not a subjective review; it is based on defined metrics that should be tied to your specific role.

Masterclass Deep Dive: Understanding Your OPPE Report

As part of your re-privileging, you should be able to review your OPPE report. Understanding the metrics you are being evaluated on is critical. A strong OPPE is the key to a smooth re-privileging process. For a pharmacist, these metrics could include:

Category Potential Pharmacist OPPE Metrics Data Source
Clinical Outcomes
  • Percentage of your empaneled diabetes patients with A1c at goal (<7% or <8%).
  • Time in Therapeutic Range (TTR) for your managed anticoagulation patients.
  • Percentage of your heart failure patients on guideline-directed medical therapy.
 EHR Reporting, Disease Registries
Process Adherence
  • Adherence to institutional protocols (e.g., insulin titration, anticoagulation dosing).
  • Documentation completeness rate.
  • Rate of interventions documented and accepted by physicians.
 EHR Audits, Pharmacy Department Records
Professionalism & Peer Review
  • Peer reviews from collaborating physicians and other pharmacists.
  • Patient satisfaction scores (if applicable).
  • Absence of patient complaints or behavioral issues.
 Formal Peer Review Surveys, Patient Relations Department

A favorable OPPE report, demonstrating competent and safe practice, will lead to a recommendation from the Department Chair and Credentials Committee for renewal of your existing privileges. If a concern is identified, or if you are requesting new privileges, it may trigger a more intensive Focused Professional Practice Evaluation (FPPE), where your practice is more directly observed or audited for a set period of time.

7.5.5 The Linchpin: Building Your Personal Credentialing Vault

The only way to effectively manage this continuous cycle of renewals and re-verifications is to build a systematic, organized, and proactive personal record-keeping system. Relying on memory or a shoebox of old documents is a recipe for disaster. You need to create a central, easily accessible “Credentialing Vault.” In the modern era, this should be a secure, cloud-based digital system.

This system has two key components: a tracking mechanism (a detailed spreadsheet) and a document repository (a well-organized set of digital files). This personal vault becomes your single source of truth, allowing you to respond to any request from an MSO or payer within minutes, not days.

The Digital Document Repository

Your first task is to gather every single professional document you possess and create a high-quality, clearly labeled PDF scan of it. Store these in a secure cloud service (e.g., Google Drive, Dropbox, Microsoft OneDrive) with multi-factor authentication enabled. Organize them into a logical folder structure.

Sample Folder Structure:

  • /Professional_Credentials
    • /CVs (Containing dated versions of your CV)
    • /Diplomas_and_Training (PharmD, Residency Certificates)
    • /State_Licenses (Subfolders for each state)
    • /Board_Certifications (BCPS, BCACP, etc.)
    • /DEA_and_CDS
    • /Malpractice_Insurance (Subfolders for each policy year)
    • /NPI (Your NPI confirmation letter)
    • /NPDB_Self_Queries

The Master Tracking Spreadsheet

This spreadsheet is the command center of your professional life. It lists every credential, every number, and every critical date. Reviewing this spreadsheet once a month should be a professional habit.

Masterclass Template: The Ultimate Credentialing & Renewals Tracking Spreadsheet
Credential / Item Issuing Body ID / Number Date Issued Expiration Date Next Action Due CE Requirements File Location
State Pharmacist License (CA) California Board of Pharmacy RPH12345 07/01/2020 06/30/2026 04/01/2026 30 hours every 2 years /Licenses/CA_License_2024.pdf
Board Certified Ambulatory Care Pharmacist (BCACP) Board of Pharmacy Specialties (BPS) 987654 12/15/2021 12/14/2028 12/15/2027 100 hours or Exam /Certs/BCACP_Cert.pdf
NPI NPPES / CMS 1234567890 08/10/2019 N/A N/A N/A /NPI/NPI_Letter.pdf
CAQH Re-Attestation CAQH 99887766 N/A Every 120 Days 02/15/2026 N/A Online Profile
DEA Registration Drug Enforcement Admin. BS1234567 09/01/2022 08/31/2025 06/01/2025 1-time 8-hr SUD training /DEA/DEA_Cert.pdf
Malpractice Policy HPSO Policy# ABC-123 10/01/2025 09/30/2026 08/01/2026 N/A /Malpractice/Policy_2025.pdf
Health System Re-Privileging Anytown Medical Center N/A 11/15/2025 11/14/2027 08/15/2027 Dept-specific CME MSO Application
The 90-Day Rule: Your Calendar is Your Ultimate Defense

For every “Expiration Date” or “Next Action Due” on your spreadsheet, you must immediately create a calendar event on that date and set multiple reminders starting 90 days before the deadline. A 90-day lead time gives you ample buffer to complete any required CE, fill out renewal forms, and resolve any unexpected issues without the stress of an impending deadline. Running your professional life from your calendar is not just a good idea; it is an essential risk-management strategy.