Find answers to common questions about provider credentialing, commercial payer enrollment and Medicare. These processes are related, but their requirements and timelines differ. If you need help applying the guidance to your practice, talk with PPS.
Credentialing and provider enrollment
What is provider credentialing?
Provider credentialing verifies a healthcare provider’s qualifications, such as licensure, education and training. It is part of joining many insurance networks, but credentialing approval alone does not establish a contract, enrollment record or effective participation date.
What is the process for provider enrollment?
The process for provider enrollment typically involves submitting an application with required documentation, such as proof of licensure, malpractice insurance, and education and training credentials. The application is then reviewed by the insurance network or healthcare organization to determine eligibility for participation. Learn more here about the insurance credentialing process.
What are the requirements for provider credentialing?
Requirements for provider credentialing vary depending on the insurance network or healthcare organization. Typically, providers must have a valid license to practice, malpractice insurance, and meet certain education and training standards.
How long does it take to complete provider enrollment?
Provider enrollment can take several months, depending on the payer, location and completeness of the application. Confirm each payer’s current processing expectations and allow time for follow-up. A single estimate does not apply to every commercial plan or Medicare application.
What documents are needed for provider credentialing?
Documents commonly include proof of licensure, malpractice coverage, education and training, plus the information required by the payer or healthcare organization. Use our credentialing checklists to prepare for a new practice or a provider joining an existing group.
How often do I need to renew my provider enrollment?
Follow each payer’s recredentialing or revalidation schedule. Many commercial plans recredential every three years, subject to applicable requirements. Medicare generally requires revalidation every five years, or every three years for DMEPOS suppliers, and may require an off-cycle revalidation. See the CMS revalidation guidance.
What is CAQH and how does it relate to provider credentialing?
The CAQH Provider Data Portal, now offered by DataSpring, powered by CAQH, lets providers maintain professional information and share it with authorized participating plans. It supports credentialing data collection; it does not replace each payer’s enrollment or contracting process. Learn how to register with CAQH.
What is the National Provider Identifier (NPI) and do I need one?
The National Provider Identifier (NPI) is a unique 10-digit identifier for healthcare providers. HIPAA-covered healthcare providers must obtain an NPI, and it is required for Medicare enrollment. Type 1 identifies an individual; Type 2 identifies an organization. See our NPI registration guide.
What are the common reasons for provider credentialing denials?
Incomplete information, qualification discrepancies and failure to meet a payer’s standards can delay or prevent approval. A malpractice claim or other disclosed history may require additional review; it does not automatically mean every payer will deny the application. Review the payer’s stated reason and any correction or appeal process.
How can I check the status of my provider enrollment application?
To check the status of a provider enrollment application, contact the insurance network or healthcare organization where the application was submitted. They should be able to provide an update on the status of the application.
Medicare provider enrollment
What is Medicare provider enrollment?
Medicare provider enrollment establishes an eligible provider or supplier’s enrollment with CMS. For providers seeking payment, approval grants billing privileges subject to Medicare requirements. Our PECOS guide explains the online enrollment process.
What are the Medicare enrollment requirements?
You must be an eligible provider or supplier type, meet the applicable licensure and program requirements, obtain the appropriate NPI, and complete the correct enrollment application. Requirements vary by provider type. Review CMS enrollment guidance and our Medicare enrollment service.
How do I submit a Medicare provider enrollment application?
Apply online through PECOS or submit the appropriate current CMS enrollment form to your Medicare Administrative Contractor (MAC). Complete the certification and any required signatures, and provide the supporting documents requested for your enrollment scenario.
What documents are needed for Medicare provider enrollment?
The required documents depend on your provider type and enrollment scenario. They may include licensure, business and tax identification, ownership information, practice locations and EFT banking documentation. Use the document checklist in PECOS or the current CMS application rather than assuming every provider needs the same attachments.
How long does it take to complete Medicare provider enrollment?
The length of time to complete Medicare provider enrollment can vary depending on the completeness of the application and any additional documentation that may be required. Typically, the process takes several weeks to a few months to complete. It is important to submit a complete and accurate application to avoid delays in processing.