The Ultimate FAQ for Provider Enrollment Part 1

“There are naive questions, tedious questions, ill-phrased questions, questions put after inadequate self-criticism. But every question is a cry to understand the world. There is no such thing as a dumb question.” —Carl Sagan


There are no stupid questions, especially when it comes to credentialing and provider enrollment. In fact, it seems the supply of questions is endless, and that’s because when it comes to provider enrollment, there is a lot to know.


Fortunately at CredentialGenie, we have a very knowledgeable resource in Jennifer Jinzo-Chavez, our director of credentialing, who helped us answer every question we could think of for this ultimate FAQ for credentialing and provider enrollment. There were so many questions, and the answers were so detailed, we had to split it into multiple parts. Please enjoy part 1 below.


How do I begin credentialing for provider enrollment?

First order of business is to decide how to bill.


“Determining how you are going to bill for your services is based on your business structure and will influence provider enrollments with most payors,” said Jinzo-Chavez. “If you’re a sole proprietor and plan to use your social security number, we advise against this."


“Finalize your legal business name and legal structure, establish your Tax ID and other official documents well in advance of beginning the credentialing process,” Jinzo-Chavez says. “Any changes to these items can delay the process, or require a complete do-over.”


Do your homework and use our provider credentialing and enrollment checklist to get your business details in order.


Absolute Basics

Before a provider can be enrolled with government or commercial insurance carriers, each applicant will need a National Provider Identifier (NPI) number, which is issued through the National Plan & Provider Enumeration System (NPPES).


“There are two types of NPI numbers:


  • Type 1 — Health care providers who are individuals, including physicians, dentists, and all sole proprietors. An individual is eligible for only one NPI.

  • Type 2 — Health care providers who are organizations, including physician groups, hospitals, nursing homes, and the corporation formed when an individual incorporates him/herself.”


Individual providers who are also incorporated need to obtain both an NPI (Type 1) for themselves) and an NPI (Type 2) for their corporation or LLC.


Source: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/enrollmentsheet_wwwwh.pdf


Enrollment with Government Insurance Carriers

Provider Enrollment in government health programs such as Medicare, Medicaid and others involves the submission of standard forms to intermediaries who handle the administrative functions for reviewing and paying claims.


First, NPIs must be established, as described above in Absolute Basics.


Next, Medicare requires that providers enroll through its online enrollment system. The Provider Enrollment, Chain, and Ownership System (PECOS) system “enables registered users to securely and electronically submit and manage Medicare enrollment information.” Submitting electronically is the best practice,” say Jinzo-Chavez, “but there is also a paper form that can be submitted if the circumstances require it.” By the way, check out our blog “How PECOS simplifies the Medicare provider enrollment process”.


Once these initial steps are complete, your designated Medicare Administrative Contractor (MAC) can answer questions and process enrollment requests. As defined on the Centers for Medicare and Medicaid Services (CMS) website, a “MAC is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims.”


Part B suppliers include physicians, non-physician practitioners, Ambulance Service Suppliers, Independent Diagnostic Testing Facilities, Ambulatory Surgical Centers, Mammography Centers, Clinics & Group Practices, Portable X-ray Suppliers, Independent Clinical Laboratories and Radiation Therapy Centers. You can find a contact list here and the MAC for your area(s) here.


Enrollment with Commercial Insurance Carriers

Enrolling with commercial insurance networks and becoming an in-network provider is a different process than enrollment with government plans.


In fact, each health plan requires a Credentialing and Contracting process unique to their specific needs. Requirements for acceptance vary based on the type of provider being credentialed, the state where service is being rendered, and other stipulations.


Most insurance carriers require the completion of an application to begin the process. During the credentialing process, the insurance carrier will want to verify a provider’s qualifications, practice history, certifications and registration to practice in a health care field.


As a point of reference, check out United Healthcare and Aetna for examples of provider enrollment processes with major commercial insurance networks.


Commercial insurance carriers usually adhere to accreditation and certification standards established by organizations like the National Committee on Quality Assurance (NCQA) or URAC (formerly known as the Utilization Review Accreditation Commission). These bodies developed minimum standards that health plans can use to identify qualified individuals and facilities to provide quality care to their members. In this great article from The Credentialing resource Center, you can familiarize yourself with the major health plan accreditors.


Commercial insurance companies also usually contract with the Council for Affordable Quality Healthcare (CAQH), as well as other state-specific entities, to collect the credentialing and recredentialing application data required to verify elements of the credentialing application and process.


Successful completion of your CAQH profile is critical. You will need to have accurate and available documents and information including:


  • Basic Personal Information

  • License

  • Certifications

  • Education and Training

  • Medical /Professional school

  • Graduate school

  • Internships and residencies

  • Fellowships and preceptorships

  • Teaching appointments

  • Specialties and Board Certification

  • Practice Location Information

  • Practice name and type

  • Address and contact information

  • Billing, office manager and credentialing contact

  • Services, certifications, limitations and hours of operation

  • Partners and covering colleagues

  • Hospital Affiliation Information

  • Malpractice Insurance Information

  • Work History and References

  • Disclosure and Malpractice History


Source: CAQH ProView profile registration guide


With your CAQH profile underway, make sure to complete the provider’s initial application by completing all application questions and outstanding required fields, authorizing participating organizations access to your data, attesting to application data, and uploading any supporting documentation.


The materials you need to complete your CAQH application are referenced above,,” Jinzo-Chavez explained. “But other information may be required such as practice location(s), practice address(es), billing, address(es), Tax ID(s) , NPI(s), and other identifiers such as Medicare, Medicaid etc.), and Malpractice insurance policy(ies).”


As a final tip, Jinzo-Chavez added, “Making sure your CAQH profile is monitored, kept up to date and error-free, and that licenses and documents are not expiring in the near future, goes a long way towards creating a seamless credentialing process.”


“With these steps completed, you’re probably meeting about 90% of an insurance carrier’s requirements,” said Jinzo-Chavez. “But don’t be surprised if you also need quick access to additional items, such as your driver’s license, social security card, and resume, so the insurance companies can begin their process of reviewing and accepting provider applications for enrollment.


Can providers see patients before payor credentialing is done?

“Yes,” said Jinzo-Chavez. “However,” she warns, “you are seeing patients out of network, or as a non-participating provider, and many payors—probably 90%—will not pay retroactively for scenarios where a provider delivers care prior to an effective date.” Not only is there a risk of the provider not being reimbursed, but the patient is likely to pay more for the care.


According to this Nuvasive article, “Healthcare providers that are out-of-network have not agreed to accept the insurance plan’s negotiated fees and could balance bill the patient. Without a signed agreement between the healthcare provider and the insurance plan, the healthcare provider is not limited in what they may bill the patient and may seek to hold the patient responsible for any amounts not paid by the insurance plan.”


Can you retroactively bill Medicare after credentialing is done?

“This is a great question,” Jinzo-Chavez admitted. “Yes, you can file Medicare claims up to 12 months in arrears. However, most Medicare intermediaries will only honor reimbursements that are backdated 90 days.”


Regarding claims & appeals, the CMS states “Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. For example, if you see your doctor on March 22, 2021, your doctor must file the Medicare claim for that visit no later than March 22, 2022.”


How long is the credentialing process?

“It depends on whether a provider has already been contracted or not,” says Jinzo-Chavez. “A new provider who has not previously been credentialed or contracted can take 60 to 180 days . This is because the process includes the time required to complete primary source verification, which is a time-consuming endeavor.”


According to the American Academy of Family Physicians’ article “Getting New Physicians Credentialed Quickly”, the delays are due to “poor planning on the part of physicians and practices and the MCOs' desire to meet National Committee for Quality Assurance (NCQA) standards.”


How much does it cost to credential a provider?

For some government insurance, depending on your provider type, you may be required to pay an application fee. But physicians, some non-physician practitioners, some physician organizations, and non-physician organizations don’t pay an application fee, as per the CMS.


Commercial insurance carriers don’t charge an application fee either.


The costs related to provider credentialing come from the time it takes to complete the process, and the salaries of the administrators performing the process.


There is an opportunity cost to the practice and the provider when they can’t bill for services due to delayed credentialing.


There is also a payroll cost for the credentialing specialists, coordinators, managers, and other support staff that do the actual work of credentialing and enrollment. Administrators must collect documents, verify their source, complete and submit applications, make phone calls, do research, and communicate with the providers.


These resources are either working for you full-time or being outsourced on a contract basis. If you’re considering one or the other, read our post “How to Decide Between In-House and Outsourced Credentialing Services.”


How often does a provider need to be re-credentialed?

“Typically, most payers will recredential a provider between 3 to 5 years,” says Jinzo-Chavez.


Here is what Cigna says about re-credentialing, “Recredentialing is required every three years in most states. The recredentialing process requires you to meet the same criteria as you did during the initial credentialing process.” You can review Cigna’s credentialing criteria here.


Humana offers similar direction about re-credentialing.


“Providers are re-credentialed a minimum of every three years. As part of the re-credentialing process, Humana – CareSource considers information regarding performance to include complaints and safety and quality issues collected through the quality improvement program, in addition to information regarding sanctions collected from the NPDB, Medicare and Medicaid Sanctions and Reinstatement Report, Medicare Opt-Out and the HHS/OIG and GSA (formerly EPLS). Providers will be considered re-credentialed unless otherwise notified.”

Source: https://www.caresource.com/documents/2014-ky-provider-manual-credentialing-and-recredentialing/


“The key to avoiding issues when re-credentialing is to make sure that quarterly attestations with each health plan are kept up-to-date,” add Jinzo-Chavez. “Some carriers send notifications for renewal, and some do not.”


To be on the safe side, effective dates and renewal time frames should be tracked in credentialing software or some other reliable repository. It is also a good practice to maintain a provider’s CAQH profile regularly.”


How long do you have to keep credentialing files?

“Some states may have document storage timeline mandates, but I’m not familiar with them,” said Jinzo-Chavez. “Accredited facilities likely have these types of requirements defined in their policies and procedures. During my time in hospital administration, our best practices included storing documents electronically, and rarely were hard copies older than 3 years kept.”


Credentialing software solutions like CredentialGenie have mostly taken over this aspect of credentialing document management. Any type of document can be digitized, stored securely, tracked for expiration dates, and available for recall with a mouse click.


What are the steps involved in the credentialing process?

This is a good question, and we answer it in detail above in the section titled “How do I begin credentialing for provider enrollment?”


What is the difference between contracting and credentialing?

The contracting and credentialing processes are distinctly different, and can occur simultaneously, but are both required steps for enrolling a provider with an health plan network.


Contracting is the business end of provider enrollment. This aspect of enrollment includes the details of a legal contract between the health plan and the provider. Once a network accepts a provider’s request to join and work in-network, the provider agreement/contract contains “information about compensation, billing, payment, network participation, provider licensing and insurance, provider credentialing, maintenance of records, termination, and state contracting and filing requirements.”


“Credentialing, on the other hand,” says Jinzo-Chavez, “is the process of vetting the individual practitioners. This includes, at a minimum, the collection and verification of a provider’s professional and educational documentation and qualifications.”


“During this phase,” she continues, “we ensure providers are who they say they are. We ensure they are appropriately licensed, without sanctions, not opted-out of Medicare or Medicaid programs, etc. Once a credentialed provider has been approved by a credentialing committee, they can be linked to a contract to be reimbursed for services rendered.”


There can be confusion. “Sometimes providers receive a letter from a health plan indicating the credentials have been approved. However, that is not always an indication of readiness to bill,” says Jinzo-Chavez. “When you receive this correspondence, contact the plan and confirm the provider’s contract approval date, or billing effective date. There is not not usually a long delay—approximately 30 days—between receiving an approval on credentials and an effective date for a contract/billing.”


When you are sure that you have an effective date, which would indicate a provider has been “loaded/linked” to an agreement, ask the health plan contact if the provider can begin billing immediately.


“Health plans have multiple teams handling contracting, credentialing, claims and provider implementation/loading team,” Jinzo-Chavez explained. “There can be a lag between departments and systems. So, if you submit a claim the same day that you receive the contract effective date, your claim could still be rejected. I would recommend allowing 7 to 14 days, and most health plans will request this as well.”


Can I do credentialing myself?

Sure, you can. But it is a full-time job, if done right, and requires strong organization skills, attention to detail and patience.


As a credentialing services company, we get asked this all the time. Go-getting sole providers, or those who have seriously limited budgets, are the most common types of DIY credentialers. There are certainly some success stories. However, we mostly hear horror stories from providers or practice managers who found it difficult to care for patients or do their full-time job in addition to the time required on hold or playing phone tag with a commercial insurance plan to see why a Tax ID copy/paste error caused 6 months of denied claims.


If you’re on the fence as to whether you should try to do credentialing on your own, keep it in-house, or hire a 3rd party, check out our article “How to Decide Between In-House and Outsourced Credentialing Services.”


Is credentialing hard?

Because there is no single, standardized set of requirements for credentialing a provider for all health plans, the variations and unique requirements make credentialing difficult and frustrating.


In the end, credentialing is about much more than just completing paperwork. It’s about putting the correct information in the right place and submitting it to the right person in the specified format and timeframe.


Even seasoned pros can make mistakes, and those errors have far reaching effects that hurt a practice’s bottom lines. Entering the incorrect Tax ID in an insurance application can potentially go undiscovered for months and, once detected, require the entire process to be done again. Meanwhile, your providers and practice are not getting reimbursed for their services. There are many potentially devastating possibilities that can arise downstream from even the simplest of mistakes, so it makes sense to leave the work to the knowledgeable professionals.


Stay tuned for Part 2

Whew! That was a lot of information. Make sure to check back for part 2 when Jennifer answers even more questions about credentialing and provider enrollment.