Provider credentialing often takes several months. Here is what happens at each step, what slows it down and how to avoid starting to see patients before you can bill.
Credentialing is the process insurance companies use to check a provider's qualifications before adding them to their network. Until it is complete, claims for that provider may be denied or paid out of network. That is why it pays to start early.
A typical timeline
Timelines vary by payer, state and provider type, but many commercial payers take roughly 60 to 120 days from a complete application, and some take longer. Medicare and Medicaid have their own processing times. Missing documents or unanswered payer questions can add weeks.
Step 1: Gather documents
Most applications need a current state license, DEA registration where applicable, board certification, malpractice insurance, a CV with full work history, education and training details, and practice information such as tax ID and service locations.
Step 2: NPI, PECOS and CAQH
Each provider needs an individual NPI, and groups need an organizational NPI. Medicare enrollment is handled through PECOS. Many commercial payers use the CAQH ProView profile, which must be complete, have all documents uploaded and be re-attested regularly.
Step 3: Payer applications
Applications go to each payer the practice wants to work with. Some use online portals, some use CAQH directly and some still use paper forms. Each one is tracked separately.
Step 4: Follow-up
This is where most delays happen. Payers may ask for extra documents, corrections or signatures. Regular follow-up by phone and portal keeps applications moving.
Step 5: Contracting and effective dates
Once credentialing is approved, the payer issues a contract or participation agreement and an effective date. Only then should claims be billed as in-network.
How to avoid delays
- Start as soon as a new provider signs on, ideally several months before their start date.
- Keep CAQH complete and re-attested on time.
- Answer payer requests quickly and keep copies of everything sent.
- Track Medicare revalidation and payer re-credentialing dates.
At Healthcare Providers Care, credentialing and enrollment are free for the first two months for providers who use our billing service. Contact us to get started.
Sources
This article is for general information only and is not legal or compliance advice. Always check the latest guidance from CMS and your payers.