Credentialing and Provider Enrollment
Payer enrollment, CAQH maintenance, Medicare revalidations and re‑credentialing — prepared, filed and followed with the payer until the effective date comes back in writing.
What Is Included
Initial Enrollment
New providers enrolled with the payers your practice already contracts with.CAQH Maintenance
The profile kept current and re‑attested, so payers are not pulling stale data. Part of the Monthly Plan, or ordered per attestation.Medicare Revalidations
Medicare revalidations filed before the deadline. Date tracking is part of the Monthly Plan.Re-Credentialing
Existing providers re-credentialed on each payer's own cycle.Group and Facility Enrollment
Group NPI, additional locations and facility enrollment alongside individuals.Contract Negotiation
Participation agreements and reimbursement rates negotiated with payers, with the final say yours. Ordered separately, per payer contract.
How It Works
1. Document Collection
We tell you exactly what each payer needs and collect it once, rather than in installments.
2. File Preparation
The application built complete, with every supporting document attached.
3. Filing
Filed with the payer as soon as the document set is complete.
4. Payer Follow-Up
Tracked with the payer until a decision comes back.
5. Effective Date Confirmed
The effective date recorded in writing and passed to billing.
Who We Credential
Provider type changes what a payer asks for, so the rules are checked for each one before filing.
- Physicians (MD and DO)
- Nurse Practitioners
- Physician Assistants
- Psychiatrists
- Psychologists
- Licensed Counselors
- Social Workers
- Groups and Facilities
Plans and Payers We Enroll With
Every plan type a practice bills, with the rules checked per payer and per state.
Medicare and Medicaid
Federal and state programs, including Medicare revalidation.Commercial and Private Plans
National and regional carriers, through each payer's own process.Behavioral Health and Managed Care Plans
Carve-out and managed-care networks, including closed panels.Workers' Compensation
Networks for practices that treat injured workers.
One Business Day From a Complete Document Set to Filing
Excluding weekends and US federal holidays.
- Checklist Up FrontWhat complete means for each payer, before you start collecting.
- Clock Starts at CompleteCounted from the day the document set is complete.
- Then the Wait Is the Payer'sOnce filed, the time is with the payer rather than with us.
What We Need From You
Every payer asks for its own set, so we confirm the list per payer before collection starts. Most enrollments draw on:
- State license for each state of practice
- DEA registration, where applicable
- Board certification, where applicable
- Current CV with month-and-year work history
- Malpractice certificate of insurance
- Individual and group NPIs, and the group's tax ID and W-9
- Practice location and billing address details
- CAQH profile access, or we set the profile up with you
Credentialing and Enrollment in Detail
Credentialing proves a provider is qualified; enrollment adds them to the network. Each fails differently.
Payers process applications on their own schedule and nobody outside the payer can change it. What can be changed is the number of times the application goes back and forth before the payer starts that clock. Almost every avoidable delay in insurance credentialing is an incomplete or inconsistent file.
Incomplete means a required document is missing: a current DEA certificate, a signed CMS-855I or CMS-855B, a state license in the state where the service location sits, a certificate of insurance that shows the right entity, a signed reassignment of benefits (CMS-855R) linking the individual to the group. The payer pends the file, sends a request for information, and the clock stops until the document arrives.
Inconsistent means the documents disagree with each other or with the payer's records. The practice address on the application does not match the one in NPPES. The provider's name on the license carries a middle initial the application omits. The tax identification number on the W-9 belongs to a different legal entity from the one on the contract. The group NPI in PECOS has an address the payer cannot match. Each mismatch is a query, and each query is a round trip.
The remedy is to know each payer's document list before collection starts, to gather the set once, and to reconcile every identifier against NPPES, PECOS and the state board before anything is filed.
Payers process applications on their own schedule and nobody outside the payer can change it. What can be changed is the number of times the application goes back and forth before the payer starts that clock. Almost every avoidable delay in insurance credentialing is an incomplete or inconsistent file.
Incomplete means a required document is missing: a current DEA certificate, a signed CMS-855I or CMS-855B, a state license in the state where the service location sits, a certificate of insurance that shows the right entity, a signed reassignment of benefits (CMS-855R) linking the individual to the group. The payer pends the file, sends a request for information, and the clock stops until the document arrives.
Inconsistent means the documents disagree with each other or with the payer's records. The practice address on the application does not match the one in NPPES. The provider's name on the license carries a middle initial the application omits. The tax identification number on the W-9 belongs to a different legal entity from the one on the contract. The group NPI in PECOS has an address the payer cannot match. Each mismatch is a query, and each query is a round trip.
The remedy is to know each payer's document list before collection starts, to gather the set once, and to reconcile every identifier against NPPES, PECOS and the state board before anything is filed.
The effective date is the date from which the payer will pay claims for the provider under that contract. It is not the approval date and it is not the start date of employment, and a provider who sees patients before it has delivered services the payer may never pay for.
Payers treat the gap differently. Medicare allows a retrospective effective date, within limits, measured back from the date the application was received, which is one reason a complete file matters: the received date is the anchor. Many state Medicaid programs set the effective date to the approval date and pay nothing before it. Commercial payers vary by contract; some backdate to the application date, some to the credentialing committee decision, some not at all.
The billing consequence is that claims for a provider who is not yet effective have to be held, billed under a supervising or incident-to arrangement where the payer allows one, or accepted as unbillable. Which of those applies is a question to answer per payer before the provider's first day, not after the first denials arrive.
Most commercial payers, and an increasing number of Medicaid managed care plans, pull provider data from CAQH rather than asking for it directly. The profile holds the practitioner's education, training, licenses, insurance, work history and practice locations, and the provider authorizes specific payers to read it.
The profile has to be re-attested on a fixed cycle or it lapses, and a lapsed profile is invisible to the payers that depend on it. A re-credentialing that stalls with no explanation is very often a CAQH attestation that expired. Expiring documents inside the profile, the malpractice certificate and the state license in particular, need to be replaced when they renew, and a new practice location has to be added before claims from it will match.
Maintaining CAQH means holding the attestation calendar for every provider on the engagement, refreshing documents as they renew, and checking that each payer the practice contracts with is authorized to access the profile.
A payer can decline to add a provider to its network on the grounds that the panel for that specialty in that area is full. This is a network adequacy decision, not a judgment about the provider, and it is not always final.
Where the practice can show a reason the network needs the provider, a letter of interest or appeal can be filed: an underserved location, a specialty or language the network is short of, a patient population already being seen by the practice who would otherwise lose access, or an existing group contract the provider is joining. The case is made with evidence, in the payer's own terms, and the payer's response is recorded either way.
Where the panel stays closed, the practice needs to know that plainly, so the provider's schedule and the practice's payer mix can be planned around it rather than discovered on the remittance.
Related Services
Medical Billing
Charge entry, scrubbing, submission, payment posting and patient statements.Learn MoreEligibility and Benefits Verification
Coverage, benefits and patient responsibility checked before the visit.Learn MoreDenial Management
Denials worked by reason code, corrected, appealed and tracked.Learn MoreVirtual Assistants
Trained staff for scheduling, intake, records and inbound calls.Learn More
Frequently Asked Questions
What practices ask before they hand over credentialing.
Hand Over Credentialing
Pick the services you need and pay online, or talk to us about anything not on the order page.
- New Enrollments
- CAQH
- Medicare Revalidations
- Re-Credentialing
- Group Enrollment
- Medicare
- Medicaid