Credentialing 101

Insurance credentialing can be a confusing and lengthy process that will leave you frustrated. Unfortunately, you don’t get paid by third-party payers unless you are credentialed and have a contract in place.

It’s important to understand what credentialing is and what it is not. Credentialing is the process third-party payers use to evaluate your qualifications and your clinical history. They want to determine that you are who you say you are, that you don’t have any malpractice claims against you, that you are good providers with good references, that you are not a risk to them or to their members, and that you will do a good job of taking care of their members.

It’s important to realize that credentialing is not the same as contracting with third-party payers (I often hear the terms used interchangeably, but that is inaccurate).  So here is some basic information for you to know regarding credentialing.

What is it? In fancy language, credentialing is the process of establishing the qualifications of licensed professionals. In simpler terms, credentialing equates to being able to accept different forms of insurance at your Medical Practice. Insurance companies and healthcare agencies use credentialing to ensure all practitioners meet their necessary requirements and are truly qualified. Unfortunately, every organization’s credentialing process is a little different. For this reason, you need to contact each organization or agency you want to be credentialed with and ask them their specific requirements for getting credentialed. You should also inquire if there are any fees associated with each credentialing application you submit.

What Documentation is Required for Credentialing? Malpractice NPI number State Issued License Board Certificate Curriculum Vitae (CV) X-Ray Certs/CLIA Certs (if those services are provided) How Long Does Credentialing Take? The short answer – a long time! Credentialing can take anywhere from three months to more than a year. Several factors influence the length of time it takes, including if you submit your application electronically or by mail and if there are any errors or if paperwork is sent back for any reason.

Why Should I Get Credentialed? Getting credentialed may lead to higher reimbursements or being listed as a preferred provider in an insurance directory. Some insurance companies will not pay you at all if you are not credentialed.

What is Facility Credentialing? Some organizations will credential both your Medical Practice facility and your providers. Facility credentialing ensures your facility meets the requirements of the organization credentialing you.

Are There Tips for Medicare Credentialing? For Medicare credentialing it is in your best interest to credential electronically through the PECOS system. This will require you to have the NPI login for the provider. If you do not have the login information, you may call the National Plan and Provider Enumeration System (NPPES) and they will reset the password for the physician. You can also submit a paper application, but it can take up to 120 days just for your paper application to be looked at. By using the PECOS system, you cut that time to 40-60 days.

What is CAQH? The Council for Affordable Quality Healthcare (CAQH) is a website used by many insurance companies for credentialing. This site is designed to help minimize the amount of paperwork associated with your application process. By logging on to, you can fill out all the necessary information and save it. Then you can give certain insurance permission to access your information for credentialing purposes.

What is re-attestation? Four times a year you’ll receive an email from CAQH, asking for you to “Re-attest†to the information in your profile. Not doing this can cause major problems with your ability to accept insurance, as the insurance companies you are paneled with will know the lapse in CAQH. Re-attestation only takes a few minutes (if you can remember your provider number and password), so log in and get it taken care of ASAP.

What is Re-Credentialing? Each healthcare organization you are credentialed with will periodically have you re-credential. This occurs at timeframes set by each individual organization and involves verifying that all your information is still the same or submitting any updates.

Barriers for Mid-Level Providers. Credentialing can be a daunting process for Mid-level providers. Let’s discuss credentialing a Nurse Practitioner.  The NP practice authority varies from state to state, and so do insurer policies. You may find that a certain insurance company will not credential you unless your collaborating physician is also credentialed with that insurance company. Or you may find that NPs in one state have no problem getting credentialed with one insurance company, but in another state, the same company won’t credential NPs. Unfortunately, a few states still will not credential NPs directly.

How long does it take? The rule of thumb with credentialing is to allow for time. Depending on the payers, it could be weeks to months before the process is complete. When it comes to Medicare, it’s advisable to allow at least 90 days or more.

For many health professionals, it makes pragmatic sense to find a reputable service to help with medical credentialing. Not only does using a credentialing service alleviate the frustration and headache of the process (many providers have heard the ‘nightmare’ stories from their colleagues), using a service may also save money, and a reputable service will likely have better success getting you credentialed efficiently meaning you can start seeing those clients with insurance sooner, rather than later.

Medical Practice Success has credentialed hundreds of providers in multiple states.  We are familiar with the various state requirements, payor guidelines, etc. Rid yourself of all the headaches, mounds of paperwork, and confusion with the insurance companies!

Trust the experts at Medical Practice Success to help you navigate the difficult process of provider enrollment and medical credentialing all at a low cost!

Reach out to us here and we can assist your organization with all of your Credentialing needs, as well as your other revenue cycle management needs.