Credentialing vs. Privileging: What Each One Decides
Credentialing confirms that a practitioner is who they say they are and is qualified. Privileging decides what that practitioner may do at one specific facility. They run in that order, they are done by different people, and only one of them follows the provider from job to job.
Credentialing
Asks: is this person who they say they are, and qualified? License, education, training, board status, work history, and malpractice and sanction history, checked at the source.
Privileging
Asks: what may this person do, here? A facility-specific grant of the procedures and patient types a practitioner can handle, based on their competence and the facility's capabilities.
Credentialing vs. Privileging, Side by Side
| Question | Credentialing / Privileging |
|---|---|
| What it answers | Is the practitioner qualified? / What exactly may they do at this facility? |
| Who does it | Hospitals, health plans, groups, and credentials verification organizations / The facility's medical staff, approved by its governing body |
| Scope | Portable: the same verified facts follow the person / Local: privileges at one hospital say nothing about another |
| Main inputs | License, DEA, education, board certification, work history, malpractice and sanctions / Credentials plus case volume, outcomes, peer references, and facility resources |
| Output | A verified file and a credentialing decision / A delineated list of granted privileges |
| Ongoing | Re-credentialing on a set cycle / Ongoing performance review and reappointment |
The order matters. Privileging depends on credentialing: a medical staff cannot decide what someone may do until it has confirmed who they are. For hospitals in Medicare, the Conditions of Participation put both steps in writing. The medical staff must examine the credentials of every candidate and recommend appointment to the governing body (42 CFR 482.22(a)(2)), and the medical staff bylaws must include criteria for determining the privileges granted to each practitioner (42 CFR 482.22(c)(6)).
Payer enrollment is a third, separate track. Being credentialed by a health plan lets a provider bill that plan; it grants nothing at a hospital. Our provider credentialing guide covers the payer side.
How Credentialing Works
Credentialing collects an application, then confirms each claim with the organization that issued it, a step called primary source verification. A diploma copy from the applicant is not enough; the school, the licensing board, or the certifying board has to confirm it.
- State license, checked with the licensing board, and DEA registration where the practitioner prescribes controlled substances.
- Education, residency, and board certification.
- Work history and gaps, and peer references.
- Malpractice and adverse-action history. Hospitals must query the National Practitioner Data Bank when a practitioner applies for staff membership or privileges, and every 2 years after (45 CFR 60.17).
- Exclusion and sanction screening against the OIG exclusion list.
Many groups pull much of this from the provider's CAQH profile; see the CAQH credentialing guide. Our credentialing checklist tracks each item per provider.
How Privileging Works
The practitioner requests specific privileges, usually from a department's delineation form. The department chair and the credentials committee review training, recent case volume, and outcomes for each procedure requested, the medical executive committee recommends, and the governing body grants or denies. The governing body has to ensure selection is based on “individual character, competence, training, experience, and judgment” (42 CFR 482.12(a)(6)).
New privileges and ongoing review
A newly granted privilege is usually watched more closely for a period, and existing privileges are reviewed continuously and at reappointment. Accreditors call these focused and ongoing professional practice evaluation (FPPE and OPPE). Most hospitals reappoint on a two-year cycle, which lines up with the two-year NPDB query requirement.
Telemedicine: credentialing by proxy
Credentialing and Privileging FAQ
Does a private practice need to privilege its providers?
Not in the hospital sense. A clinic still credentials its clinicians before they see patients, and it should define what each role may do in writing, especially for nurse practitioners and physician assistants whose scope depends on state law. See the NP and PA credentialing guide.
Can someone be credentialed but have no privileges?
Yes. A physician can be fully credentialed with every major health plan and hold no hospital privileges at all, which is common for office-based specialties.
Is software worth it for this?
Once you track more than a handful of providers, expiration dates and re-credentialing cycles become the hard part. Our comparison of credentialing software covers tools that handle both credentialing and privileging.