What practices should know before starting credentialing

Credentialing is the process by which a healthcare provider's professional qualifications are verified and approved by payers, facilities, or both. In the context of payer enrollment, it means applying to join an insurance plan's network so that the provider can bill that payer for services rendered to its members. Without credentialing and enrollment, claims submitted to that payer will be rejected, the provider has no contractual relationship with the plan that would entitle them to reimbursement.

For a new practice or a new provider joining an existing practice, this process must be completed before the provider can be paid by the payers they intend to participate with. The practical implication is that credentialing must begin before a provider sees their first patient, not after, if uninterrupted billing is the goal.

These terms are often used interchangeably, but they refer to different parts of the process. Credentialing refers to the verification of a provider's qualifications, confirming education, training, licensure, board certification, work history, and malpractice history through primary source verification. Enrollment refers to establishing a billing relationship with a specific payer, completing the application, signing the participating provider agreement, and receiving an effective date for participation.

• Credentialing: verification of professional qualifications and background
• Enrollment: completing the payer application and establishing network participation
• Both must be completed before a provider can bill a given payer
• CAQH ProView is the central repository that supports the credentialing piece for most commercial payers
• Government payer enrollment (Medicare, Medicaid) has its own separate application process

Delays in credentialing are frequently caused by missing or outdated documentation discovered after an application has already been submitted. Organizing everything in advance, before the first application is sent, eliminates the most avoidable delay category. A complete documentation package should include current licenses, DEA registration, malpractice coverage documentation, board certifications, work history for the past five to ten years, and any professional references required by payers.

• Current state medical license with expiration date
• DEA certificate, if applicable, with expiration date
• Board certification documentation, if applicable
• Current malpractice insurance certificate with coverage amounts
• Curriculum vitae with complete training and work history
• CAQH ProView profile set up and fully attested
• NPI number confirmed and registered at npiregistry.cms.hhs.gov

Credentialing timelines vary significantly by payer. Government payers typically take 60-120 days. Commercial payers vary widely, some process applications in 45-60 days, others may take 90-180 days or longer depending on application volume and payer-specific processes. Practices should assume the longer end of these estimates when planning provider start dates and when communicating with patients about which plans a new provider will participate with.

Starting the credentialing process too late, or waiting until a provider has already begun seeing patients, creates a gap during which services may not be billable. This gap represents real revenue that cannot be fully recovered even if credentialing is eventually completed.

CAQH ProView is a centralized repository that collects and stores provider credentialing information. Most commercial payers use CAQH data as part of their credentialing review, which means a complete and current CAQH profile can significantly reduce the documentation burden for individual payer applications. Providers must authorize each payer to access their CAQH data and must re-attest their profile regularly, typically every 120 days, to keep it active.

• Create a CAQH ProView account before beginning payer applications
• Complete all sections of the profile with accurate, current information
• Upload required documentation including licenses, certifications, and malpractice insurance
• Set a calendar reminder for CAQH re-attestation before the 120-day window expires
• Authorize each payer to access CAQH data as part of the application process