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Credentialing Agent · User Manual
Credentialing Agent Manual
A resident provider-credentialing specialist. It verifies providers against primary sources, screens exclusion lists continuously, tracks every credential expiration and re-credentialing deadline, parses uploaded documents, and drafts payer enrollment — so a provider never silently goes non-billable.
Two promises. Human-in-the-loop: the agent verifies, assembles, and drafts — a licensed human signs every external submission and attestation. Provider data only: it works on providers, not patient charts, so it carries minimal PHI; every exclusion hit or discrepancy is flagged for a human, never auto-cleared.
What it does
- NPI verification against the CMS NPPES registry — confirms the NPI is active and matches the name/taxonomy.
- Exclusion screening against the OIG-LEIE and SAM.gov lists — continuously, not just at onboarding.
- Expiration monitoring — tracks every license, DEA, board cert, and malpractice COI, and opens a renewal task with escalating reminders (30/14/7/1 days) so nothing lapses.
- Document intake — upload a license/DEA/cert photo or PDF; it extracts the credential number, state, and expiry automatically and re-screens.
- Enrollment tasks — per-payer/facility enrollment and re-credentialing tracked to completion, each routed to a human for one-click approval before submission.
- Optional CAQH sync (BYO) — connect your CAQH Credentialing API to auto-fill credentials and track the 120-day attestation deadline.
How it works
| Step | What happens |
|---|---|
| Add a provider | Enter name + NPI (or upload a document). Screening runs automatically: NPI + OIG + SAM. |
| Continuous watch | A daily monitor re-screens exclusions monthly and checks every expiration; reminders escalate as deadlines near. |
| Enrollment | Create an enrollment/re-cred task; the agent assembles the evidence and drafts the application. |
| You approve | Submitting a task emails you a one-click Approve/Reject link. Nothing external is filed until you approve. |
| Audit | Every verification, screen, and submission is logged with provenance. |
Bring your own (optional)
- CAQH Credentialing API — your organization’s API URL + username/password (HTTP Basic). When connected, “Sync CAQH” pulls a provider’s profile and attestation date.
- SAM.gov API key (optional) — enables SAM exclusion screening. NPI and OIG work with no keys.
What’s not in v1: automated primary-source verification of state medical boards, DEA, and ABMS board certs requires a paid PSV aggregator. Tell us if you need it and we’ll add it.
Using it
Talk to it in chat (“add Dr. Jane Smith, NPI 1043566623, license A123 expiring 2026-09-01”) or use the dashboard: Providers (add, screen, upload document, sync CAQH), Tasks (submit for approval), and CAQH settings. Approvals arrive by email with one-click Approve/Reject.
Guardrails
- No clinical or licensure judgment — the agent organizes and drafts; a human signs.
- Every OIG/SAM hit or NPI mismatch is flagged for review, never auto-cleared.
- Every external submission requires explicit human approval.
- Full audit trail with provenance for every action.