Credentialing & Enrollment

Enrollment, start to finish

Applications to Medicare, state Medicaid programs and commercial payers are prepared, submitted and chased through to an effective date. Medicare goes through PECOS on a CMS-855I for the individual and a CMS-855B for the group, with the reassignment of benefits linking the two. Medicaid has its own portal in every state, and many states will not finish a Medicaid application until Medicare shows active. Commercial payers pull from CAQH and then run their own committee. Timelines are set by the payer: Medicare commonly 45 to 90 days, commercial plans 90 to 180 days. The work is in submitting a complete application the first time and following up every two weeks, not in making a payer move faster than it moves.

CAQH kept current

Most commercial payers credential from your CAQH profile, and a profile that is incomplete or expired stalls every application that reads from it. CAQH requires re-attestation every 120 days even when nothing has changed. We build the profile from the document file, authorize each payer to view it, and attest on the cycle. License and DEA expirations, malpractice renewals and practice location changes are updated in the profile the week they happen, so the payer never sees a certificate that disagrees with the one on the application.

Revalidation before it bites

Medicare enrollment must be revalidated every five years, three for DMEPOS suppliers. CMS posts due dates about seven months ahead and the MAC sends a notice three to four months out, but the notice goes to the correspondence address on file, which is often a former office manager. Miss it and billing privileges are deactivated, no claims for the gap are paid, and reactivation means a complete new application. We pull each provider's revalidation date directly from the CMS list, hold it on the calendar with 120 days of lead time, and file before the notice arrives. Commercial re-credentialing, typically every two to three years, is tracked the same way.

What provider credentialing needs from you

Almost every delay is a missing or inconsistent document. Before an application goes anywhere we collect the state license, DEA registration, board certification, malpractice face sheet with claims history, work history with no unexplained gap over 30 days, hospital privileges if any, the individual NPI and CAQH login, and the practice's tax ID, group NPI and W-9. Everything is checked against everything else, because a start date on the CV that disagrees with the CAQH profile, or an NPPES taxonomy that does not match the specialty on the CMS-855I, is enough for a payer to return the application and restart the clock. Once that file exists, each new payer application is assembly, not a scramble. You get a status sheet listing every payer, the submission date, the last contact, the reference number and the expected effective date, updated as part of the weekly report.

The calendar, and what is on it

Each provider and each payer carries its own dates: Medicare revalidation, commercial re-credentialing, CAQH re-attestation every 120 days, license and DEA expiries, malpractice renewal, and the effective dates that determine when a claim may be billed under the provider's own name. Those dates sit on one calendar with lead time on each so the work starts well before the deadline. When a provider changes location, adds a service or leaves, the calendar drives the notifications each payer requires, and Medicare wants a change of practice location reported within 30 days. This is where credentialing meets claim submission: a claim billed before the effective date, or after a lapsed revalidation, comes back as a CO-16 with an N290 remark, a PR-204, or a CO-185 saying the rendering provider is not eligible for the service billed, and the cheapest way to handle it is to have never sent it.

Onboarding a new provider without losing months of revenue

The sequence for a new hire is fixed by the payers' timelines, so the only variable you control is when it starts. The document file is assembled and applications go in as soon as the offer is signed and the state license is active, ideally 90 to 120 days before the first day. Medicare goes first, because Medicare allows retrospective billing for up to 30 days before the effective date when circumstances precluded earlier enrollment, and because several commercial payers ask for an active Medicare enrollment before they will contract. Where a payer allows the new provider to bill under a supervising provider during the gap, for example incident-to rules for an NP or PA in the office under Medicare, the conditions are written down for your billing team. Where it does not, the schedule is built around the payers that have finished. You are told which payers are live each week, so scheduling and billing work from the same list.

What credentialing companies usually leave out

Most credentialing services stop at the approval letter. Two things then go wrong. The effective date is loaded incorrectly in the practice management system, so in-network claims pay at out-of-network rates and nobody notices because the claim paid. And the contract itself is filed and forgotten, so the fee schedule the payer loaded is never checked against the one you signed. Because we also run billing for most credentialing clients, every approval letter is checked against the first paid claim, and the contracted rates go into the PM system as the expected amount.