A new provider cannot be paid by a health plan until two things are complete: credentialing and payer enrollment. People use the two terms as if they mean the same thing. They don’t. And if either one is delayed, claims get denied no matter how well they are coded.
What is the difference?
| Credentialing | Payer enrollment | |
|---|---|---|
| Purpose | Verifies the provider’s qualifications | Sets the provider up to bill and be paid by a plan |
| What is checked | Education, training, licensure, board certification, work history, malpractice history | Practice locations, tax ID, group affiliation, network participation |
| Result | Approval by the plan’s credentialing committee | An effective date and provider record in the payer’s system |
The main steps
1. National Provider Identifier (NPI)
Every provider needs an individual NPI, and groups need an organizational NPI. NPIs are issued through NPPES (opens in a new tab). Keep the taxonomy code and practice address current, because payers compare them with enrollment data.
2. CAQH ProView
Most commercial plans use CAQH ProView (opens in a new tab) to collect credentialing information. Providers must re-attest that their profile is accurate every 120 days and upload current documents, such as licenses and malpractice coverage.
3. Medicare
Medicare enrollment is completed online through PECOS (opens in a new tab) or on CMS-855 paper applications, including reassignment of benefits to the group. Enrolled providers must revalidate, generally every five years (every three years for DMEPOS suppliers).
4. Medicaid
Each state runs its own Medicaid enrollment. In Georgia, for example, providers enroll through the Georgia Medicaid Management Information System (GAMMIS) web portal. Medicaid managed care plans then have their own credentialing requirements.
5. Commercial and managed care plans
Each plan has its own application, requirements and timeline. Some networks may be closed to new providers in certain areas or specialties.
Documents to have ready
- State license(s) and DEA registration, if applicable
- Board certification and education/training history
- Current malpractice insurance certificate and claims history
- Five-year work history with explanations for gaps
- NPI, tax ID (W-9) and practice location details
- Hospital privileges, if applicable
How long does it take?
Timelines vary widely by payer and by how complete the application is. Several months is common. The most effective way to avoid lost revenue is to start as soon as a start date is known and to follow up on every application until an effective date is confirmed.
Common causes of delay
- Missing or expired documents
- Addresses or taxonomy codes that differ between NPPES, CAQH and the application
- An out-of-date CAQH attestation
- Applications submitted without follow-up
- Providers seeing patients before an effective date is confirmed
Let us manage credentialing
We handle CAQH, Medicare, Medicaid and commercial applications and track re-attestations and revalidations.