Provider credentialing for new providers: a step-by-step checklist

Why credentialing new providers takes planning

Insurers pay only providers they’ve enrolled, and each one runs its own process on its own schedule. Credentialing commonly takes 60 to 120 days per payer, and it can take longer with some Medicaid programs, busy commercial plans, or applications that come back for corrections.

The practical rule is to start the week the provider signs. Most of the documents you need already exist before the first day of work, and every week of delay at the start becomes a week of unbillable visits at the end.

Documents to gather first

• State medical or professional license, plus licenses for any other states where they’ll practice
• DEA registration where the provider prescribes controlled substances, and a state controlled substance registration in states that require one
• Board certification, or current board eligibility status
• Diplomas and residency or fellowship certificates
• Current malpractice insurance certificate and claims history
• Complete work history, with written explanations for any gaps
• CV, government ID, and hospital privileges where applicable

Scan everything and check expiration dates before you file. A license or malpractice certificate that expires halfway through an application is one of the most common reasons files stall.

Provider credentialing checklist, step by step

1. NPI

Every provider needs an individual (Type 1) National Provider Identifier from NPPES. It’s free, and most providers already have one from training. If so, update the practice address and taxonomy code in NPPES so they match what you’ll put on every other application. The practice also needs its own organizational (Type 2) NPI if it bills as a group.

2. State license and DEA

The provider needs an active license in the state where care is delivered. DEA registration is tied to the state of practice, so a provider who moves states usually needs a new or updated registration before prescribing controlled substances there.

3. CAQH ProView

Most commercial payers pull credentialing data from CAQH ProView. Complete the profile in full, upload the supporting documents, authorize each payer to view it, and attest. CAQH requires re-attestation every 120 days, and a profile that lapses during an application can pause the payer’s review until it’s current again.

4. Medicare enrollment through PECOS

Enroll the provider in Medicare through PECOS, the CMS online enrollment system, and reassign their benefits to the group so payments go to the practice. If the group itself isn’t enrolled yet, that’s a separate application. Medicare allows only limited retroactive billing, generally up to 30 days, so the filing date matters. File early.

5. Medicaid

Each state runs its own Medicaid enrollment. In states that use Medicaid managed care plans, enrolling with the state program is usually only the first step, and each managed care plan credentials the provider separately.

6. Commercial payers

Apply to each commercial plan you want to participate with. If the provider is joining an existing group, this usually means adding them to the group’s contract. A new practice may also need to negotiate a contract, which is a separate step from credentialing and adds time. Some plans close their networks for certain specialties or areas, so ask before investing time in an application.

7. Confirm and record effective dates

Get each approval in writing with its effective date and any provider ID the payer assigns. Load those dates into your practice management system so claims aren’t sent to a payer before the provider is in network with it.

What slows provider credentialing down

• Mismatched information. Different addresses, names or taxonomy codes across NPPES, CAQH, PECOS and payer applications.
• Incomplete CAQH profiles or a lapsed attestation.
• Unexplained gaps in work history. Many payers ask for a written explanation of gaps longer than a few months.
• Documents expiring during the review.
• No follow-up. Applications sit in queues. Checking status every couple of weeks, and logging reference numbers and who you spoke to, keeps them moving.
• Closed panels. Some networks aren’t adding providers in your specialty or area.

Credentialing problems often show up first on the aging report, as one provider’s claims aging faster than everyone else’s. Our guide to days in A/R explains how to spot that pattern.

Billing before credentialing is complete: the risks

Practices under pressure to make a new provider productive sometimes try to bill before enrollment is final. The common shortcuts all carry risk:

• Billing under another provider’s NPI. Submitting a new provider’s services under a credentialed colleague’s number misstates who provided the care. Outside the narrow situations a payer’s written policy allows, it can lead to repayment demands and more serious trouble.
• Submitting claims before the effective date. These deny as out of network, and some plans won’t reprocess them once the provider is enrolled.
• Holding claims too long. Holding claims until approval can work with payers that backdate effective dates, but timely filing limits keep running. If approval takes longer than the filing window, those claims are lost.
• Surprising patients. Patients seen by an out-of-network provider may owe more. Tell them before the visit.

The safer approach is to book the new provider’s insured patients payer by payer as approvals arrive, and to track any held claims against each payer’s filing limit.

Getting help with credentialing

Credentialing is mostly paperwork and persistence, and it’s easy to lose weeks to a missing signature or an unanswered request. Our credentialing service handles NPI updates, CAQH, Medicare, Medicaid and commercial applications, and tracks every application and re-credentialing date.

If a new provider’s claims are already denying, or you’re not sure which payers have them loaded correctly, our free A/R audit will show it by payer and provider. Request your free A/R audit.