A new provider who cannot bill is one of the most expensive problems a practice can have. Credentialing and payer enrollment take time, and most of that time is outside your control. This guide explains what the process involves, what slows it down and how to plan so a new provider can start billing as soon as possible.
The Short Answer
Plan for two to four months for most payers, and longer for some commercial plans. Medicare enrollment is often faster than commercial payers when the application is complete. The single best thing you can do is start early, as soon as the provider’s start date is known.
Credentialing and Enrollment Are Two Steps
- Credentialing is the payer checking that the provider is qualified: license, education, training, board certification, malpractice history and work history.
- Enrollment (contracting) is the payer adding the provider to its network so claims are paid at the contracted rate.
A provider can be credentialed and still not be able to bill a payer until the enrollment or contract is complete. Ask each payer for the effective date in writing.
What You Need Before You Start
- State license and DEA registration, where required
- NPI (individual), and the group NPI and tax ID for the practice
- Board certification, education and training details
- Malpractice insurance certificate and claims history
- Work history with explanations for gaps
- A complete and current CAQH ProView profile
Missing or inconsistent information is the most common reason applications sit for weeks.
Medicare
Providers enroll in Medicare through PECOS, and the application is processed by your Medicare Administrative Contractor. A few rules worth knowing:
- Effective date. For physicians and many other provider types, billing privileges start on the later of the date the approved application was filed or the date the provider began seeing patients at that location (42 CFR 424.520).
- Billing back a short period. Those provider types may bill retrospectively for up to 30 days before the effective date when circumstances prevented enrolling in advance (42 CFR 424.521).
- Revalidation. Enrollment information must be revalidated every 5 years (42 CFR 424.515). Missing a revalidation can stop payments.
Medicaid
Each state runs its own Medicaid enrollment, and Medicaid managed care plans often credential separately. Check your state Medicaid provider portal for the current process and processing times.
Commercial Payers
Commercial payers usually pull the provider’s data from CAQH, then credential and contract. Timelines vary by payer and by state, and some networks are closed to new providers in certain specialties or areas. Ask early whether the panel is open.
What Slows Credentialing Down
- An incomplete or out-of-date CAQH profile, or one that has not been re-attested (CAQH asks providers to re-attest every 120 days)
- Work history gaps without an explanation
- Names, addresses or NPIs that do not match across applications
- Applications sent without follow-up: many stall until someone calls
- Closed panels, which need a different plan
How to Plan for a New Provider
- Start the day the start date is set. Ninety days before is a reasonable minimum.
- Complete CAQH first and authorize the payers to view it.
- Submit to all payers at the same time, not one after another.
- Track every application with its submission date, reference number and next follow-up date.
- Follow up every week or two by phone or portal.
- Do not schedule patients for a payer until you have that payer’s effective date in writing.
When to Use a Credentialing Company
A credentialing company is worth considering when you are adding several providers, opening a new location, or when nobody in the practice has time to chase applications. Ask how they track status, which payers they have enrolled providers with in your state, and whether they also handle CAQH upkeep and revalidations.
You can compare credentialing companies on PracticeVendors, or send one request and we will point you to companies that fit.
Sources: 42 CFR 424.515, 424.520 and 424.521 (eCFR). Payer and state processes change, so confirm current rules with each payer.