A new provider can’t bill most payers until they’re credentialed and enrolled, and that takes months, not weeks. The work isn’t hard. It’s long, it runs on documents, and it stalls quietly when nobody is tracking it. Start before the provider’s first day.
Gather the documents
Have these ready
- State medical license, for every state they’ll practice in
- DEA registration, and a state controlled substance registration where required
- Board certification or eligibility
- Individual NPI, plus the group’s NPI and tax ID
- CV with month and year for every position, gaps explained
- Medical school, residency and fellowship details
- Malpractice insurance certificate and claims history
- Hospital privileges or an admitting arrangement, where a payer asks
Keep them in one place, current and legible. Expired documents and unexplained gaps in a CV are common reasons an application comes back.
CAQH ProView
Most commercial payers pull credentialing data from CAQH ProView. Create or update the provider’s profile, upload the documents, list every practice location, and authorize each payer to view it. The profile has to be re-attested every 120 days, and a lapsed attestation can stall an application already in progress.
Medicare and Medicaid
Medicare enrollment runs through PECOS, CMS’s online enrollment system. The provider enrolls and reassigns their benefits to the group, so the group can bill for their services. Medicaid is state by state, and Medicaid managed care plans often credential separately on top of the state enrollment.
Commercial payers
For each commercial plan the practice contracts with, the provider is credentialed, meaning their background is verified, and then added to the group’s contract. These are often two steps, handled by two different teams at the payer. Ask each payer for its process, submit, and record the reference number.
Some payers close their networks to new providers in a specialty or an area. If a payer says its panel is closed, ask how it handles a provider joining a group that already holds a contract with it, and get the answer in writing.
When a payer approves the provider, get the effective date and the provider’s ID in writing, and confirm they’re linked to the right group and every location they’ll see patients.
Track it until it’s done
Keep one tracker with a row per payer: the date submitted, the reference number, the contact, the last follow-up, the status, the effective date and the provider ID. Follow up on a schedule, every two weeks or so, and write down what each payer said.
Until a payer’s effective date, don’t schedule the provider for that payer’s patients unless you’ve confirmed how it handles retroactive dates. Some payers allow a short retroactive window; many don’t. Billing the new provider’s visits under another physician’s NPI is not a workaround.
After the first approval
Credentialing doesn’t end. Payers re-credential providers on a cycle, commonly every three years. Licenses, DEA registrations and malpractice policies expire, and CAQH needs re-attesting. Put every expiration date on one calendar, with a reminder well ahead of each.
Medico’s team handles credentialing and enrollment for practices, with the status of every application tracked from the first form to the effective date.
