Use Case 1
Standard New-Provider Credentialing
Trigger: Provider application received and assigned for credentialing
1.Validate NPI format and Luhn check, then confirm active NPPES record
2.Sync CAQH ProView profile; flag attestation older than 12 months
3.Run primary source verification on licenses, DEA, board certs, education
4.Screen against OIG LEIE, SAM.gov, CMS opt-out, NPDB adverse actions with 35-day freshness gate
5.Pull and analyze NPDB malpractice history against settlement thresholds
6.Score packet against NCQA CR1–CR10 with per-standard deductions
7.Verify 5-year work history and flag unexplained gaps over 30 days
8.Assemble executive summary and route to credentialing committee via approval gate
✓
Committee receives a complete, audit-ready packet with every flag categorized CRITICAL/HIGH/MEDIUM and full source citation.
Use Case 2
Recredentialing Sweep
Trigger: Provider approaches NCQA-required 36-month recredentialing window
1.Pull all providers with credentialing_due_date within 90 days
2.Re-run primary source verification on licenses, DEA, board certs
3.Re-screen exclusion lists for any new matches since last cycle
4.Pull updated NPDB query for new malpractice or adverse actions
5.Compare packet against last cycle—flag material changes for committee attention
6.Route to committee with delta summary
✓
Recredentialing batches process at 5x manual throughput with zero windows missed.
Integrations
CAQH ProView
NPPES NPI Registry
OIG LEIE / SAM.gov / NPDB
State Medical Board APIs
ABMS / Specialty Board Verification
Credentialing System (symplr, Verity, MD-Staff)
Approval Workflow (RequestApproval)
Industries
healthcare
See It In Action
A sample conversation with this agent
Run the credentialing workflow on the new application from Dr. Reyes.
Pulling the application. NPI 1234567893 — format valid, Luhn passes, NPPES record active and matches the application name and credential. Running CAQH sync (last attestation 4 months ago, no critical discrepancies), then primary source verification on her CA and NV licenses, DEA, ABIM board cert, and education. After PSV I'll run OIG LEIE, SAM.gov, CMS opt-out, and NPDB adverse actions—each with a 35-day freshness check before I trust a zero-match. Targeting committee-ready packet within 4 hours unless I hit a flag.
What if the OIG exclusion table hasn't refreshed in over a month?
Hard halt. I won't pass an exclusion screen on stale data—a 40-day-old LEIE extract could miss a recent exclusion and put the plan in violation. I raise a CRITICAL operational flag, pause Step 4 for the entire queue (not just this provider), and route to ops to trigger the ETL refresh. Once the table re-syncs within the 35-day window, I resume from where I stopped without re-running prior steps.
Why is Dr. Patel's packet scoring 78 on NCQA compliance?
Three deductions: CR2 lost 10 points—his board certification verification came back from ABMS but the date format didn't parse cleanly into our PSV record, so it reads as unverified. CR6 lost 10 points—the NPDB query returned a transient error and I haven't retried yet. CR7 lost 4 points—we're at day 56 from his application date, approaching the 60-day packet assembly window. None of these are disqualifying findings; they're documentation hygiene. I can re-pull the ABMS verification and retry NPDB tonight to bring him to 98.