Credentialing and Certification for Your Pediatric Practice

The process of becoming credentialed to open a medical practice is time consuming and laborious and involves lag time in terms of completion. When beginning, be aware of which processes take the longest and which are more rapid and straightforward and prioritize accordingly. Although universal applications exist for some issues, there is little way around the busywork to be done. However, many applications ask for the same information, and keeping essential data handy and organized can save time.

Be prepared to budget at least a few thousand dollars for the process, as some entities do not charge a fee while others do. Additionally, unanticipated expenses may be incurred, such as getting duplicates of appropriately sized diplomas. At times, one may have to depend on organizations and individuals to send the necessary information. Check with the state medical society for state-specific information. ​Below are a few things to consider: 

American Board of Pediatrics ​ 

The American Board of Pediatrics (ABP) offers certification in general pediatrics as well as pediatric specialties. This information will be needed when going through the credentialing process. The ABP also maintains Maintenance of Certification documentation. Visit American Board of Pediatrics​ for more information.​​​ 

Obtaining Hospital Privileges​​ 

Hospital credentialing committees meet periodically, usually monthly. It can take several months to be approved, so start early. Fortunately, many hospitals accept that privileges are applied for and do not require the process to be complete before processing applications. Also, many hospitals will grant temporary privileges, if needed before the credentialing process is complete.  

Credentialing With Health Insurers  

Most large insurers and all MCOs will require credentialing for participation as a provider in their plans. It is necessary to start this credentialing process as soon as you have enough of the required information to do so; many insurers take 3 to 6 months, and at times, a pre- application step is required as well. Some hospitals offer credentialing services for a fee, which may save considerable time. These services often are able to negotiate contracts with insurers. Another solution is universal credentialing through the Council for Affordable Quality Healthcare in which a practice completes an online form that is then accessed by participating health plans. Reminders are sent periodically to review and update information. The CAQH ProView​ site can be accessed here.  

Occupational Safety and Health Administration  

All practices must be in compliance with Occupational Safety and Health Administration standards. These encompass a large number of requirements including employee dress, waste disposal, and universal precautions. While meeting some of these requirements is straightforward and intuitive, some may entail a process that takes several weeks. Biohazard removal, for example, may require a scheduled educational session before the office can be set up to handle biomedical waste. Thus, it is worthwhile to address this at least several weeks before anticipated opening. For additional information, visit  OSHA Compliance Assistance.  

Employer Identification Number 

All businesses require an employer identification number, also known as a federal tax identification number​. A practice attorney or accountant can obtain one for the new practice. It is also possible to obtain one online. Plan on a few weeks for this process.  

State Tax Identification Number  

Check with your state to see if a separate state tax identification number is required. A link to state agencies can be found at IRS.Gov. ​ 

State Medical License​ 

Whether starting your own practice or entering private practice as a physician employee, it is extremely important to start the license application early. States differ in their approach, but it is not unheard of for a license to take a year or more to obtain. It is not unreasonable to begin the license application process before deciding on an ultimate location. Begin gathering information from all colleges and universities attended, as well as from the residency program, and places of employment. Most state licensing boards will want copies of diplomas, residency certificates and board certification. Be prepared to explain any breaks in the educational process and don’t forget courses taken elsewhere. When in doubt, it is best to be thorough, honest, and complete with any explanations.

Some states have extra requirements, such as a special examination or letters of recommendation. Read the application early so none of these requirements are missed; notification from state boards on missing material is often slow and can waste valuable time. Most states have an online information system that provides information about the process, needed materials, and contact information specific to that state. The Federation of State Medical Boards provides an online directory of state medical and osteopathic boards as a convenient way to locate applicable board(s). View FSMB Directory.​  

Drug Enforcement Agency  

An application should be filed with the Drug Enforcement Agency (DEA) for a DEA number, which is required to prescribe any medication. This is usually a rapid process. Individuals who already have a DEA number should keep the agency informed of any address changes. For more information, visit DEA​. 

State Narcotics License  

About half of the US states require a state narcotics license. Check with the state medical board to see if a separate state-controlled substance license or permit is required. It is usually less involved to obtain this than the medical license itself.  

National Provider Identifier ​ 

In 2008, a federal requirement was initiated for all physicians to have a unique National Physician Identifier (NPI) number. Among other uses, it is the number recognized by most insurance payers and is necessary for payment for services. This is usually a straightforward process. Apply at National Provider Identifier.​ 

Business License 

In addition to federal and state licensing, be sure to check with the city and county about the possible need for obtaining a business license. If needed, this is usually an inexpensive, routine process and in most cases can be done after some of the more involved tasks are completed. Be aware of specific requirements—most will want a copy of a medical license, and many will want information about practice location, including accessibility and trash removal.  

Laboratory Certificate 

Decide if the practice will have an in-house laboratory and if so, which tests will be performed. Any testing at all—even a rapid test for blood in the stool—requires an application with Clinical Laboratory Improvement Amendments (CLIA) a bill that Congress passed in 1988 to establish quality standards for all non-research laboratory testing. CLIA mandates that virtually all laboratories, including physician office laboratories, meet applicable Federal requirements and have a CLIA certificate to operate. 

There are 3 levels of tests which correspond to 3 categories of CLIA certificates. These are Waived Complexity, Moderate Complexity, and High Complexity. This is a process that may take several months and is worth starting earlier rather than later. Some states charge additional fees and have an additional application process for in-house laboratories. A CLIA license is not required if all specimens will be sent to an outside laboratory for testing. See the Centers for Medicare and Medicaid Services brochure that summarizes CLIA regulations for additional information.