Credentialing
Verification of qualifications at the primary source, reviewed by the payer's committee. See primary source verification.
AAPC/AHIMA-certified staff · HIPAA-compliant · BAA signed with every client
Provider Credentialing and Enrollment Services for Practices in All 50 States
Every week a provider is not in network is a week of visits you cannot bill. ClainetRCM handles Medicare PECOS enrollment, Medicaid, CAQH ProView, commercial insurance credentialing, re-credentialing and payer contracting, so your providers are payable sooner and stay that way.
WeeklyStatus Update on Every Application
30-45 DaysTypical Medicare Approval With Our Payer Reps
All 50States We Enroll Providers In
Get a Free Credentialing Assessment
Send us your provider roster and target payers. We will map every gap and send you a dated plan within 24 hours.
Provider Credentialing Explained
What provider credentialing and enrollment actually involve
Provider credentialing is the process a health plan, hospital or government program uses to verify that a clinician is qualified to treat its members: licenses, education, training, board certification, malpractice history and sanctions, checked at the primary source. Provider enrollment is the application that follows, which gives the provider or group a payer ID and the right to submit claims. Payer contracting is the participation agreement and fee schedule that decide what those claims pay.
Most practices need all three with a dozen or more payers at once. Medicare requires a PECOS enrollment; every state Medicaid program runs its own portal and managed care plans credential separately; and nearly every commercial payer pulls its data from a CAQH ProView profile that must be complete and attested every 120 days. Each process depends on a correct NPI and taxonomy, a work history with no unexplained gaps, and documents that are current on the day the committee meets. Miss one element and the application returns for development, resetting a 90 to 150 day clock.
ClainetRCM runs the whole sequence for physicians, non-physician practitioners, groups and facilities. One coordinator owns each provider's file, assembles it to NCQA standards, files every payer in parallel, follows up on a fixed weekly cadence and loads the approved contract into your billing system. Then the same team tracks re-credentialing, Medicare revalidation and every expiring license so participation never lapses.
Enrollment
The application that issues a provider ID with Medicare, Medicaid or a commercial plan. See Medicare provider enrollment.
Contracting
The participation agreement and fee schedule, reviewed before you sign. See payer contracting.
Privileging
Authorization to admit and perform procedures at a facility. See hospital privileging.
Common Credentialing Problems
Where credentialing usually goes wrong, and what it costs
These are the situations that bring practices to us. Each one has a page that explains the fix in detail.
Applications that sit for months
A submitted application is not a processed one. Without weekly status calls, files wait in a payer queue and quietly expire. Our insurance credentialing process follows every payer on a fixed cadence and answers development requests the same business day.
CAQH profile out of date
An expired attestation or a missing payer authorization stalls every commercial application at once, with no error message. CAQH profile management keeps the profile attested, documented and authorized for every plan you apply to.
Missing or expired documents
Work history gaps, an expired malpractice face sheet or a missing collaborative agreement are the top reasons applications are returned. Our credentialing checklist lists every document by provider type before anything is filed.
Re-credentialing missed
Payers email the contact on file. When that person has left, the termination is the first sign of trouble. Re-credentialing services and Medicare revalidation run on one calendar with a 90 to 120 day head start.
New providers not payable
A provider who starts before credentialing is complete sees patients whose visits cannot be billed. Group practice credentialing starts onboarding before the hire date, and new practice credentialing sequences a startup so it opens in network.
Contracts signed blind
The participation agreement includes a fee schedule. Signed without review, rates below Medicare and 90-day filing limits are locked in for years. Payer contracting models every schedule against your top codes before signature.
Not sure where your providers stand? A free credentialing audit builds a provider-by-payer status matrix and a gap list you can act on.
What We Handle
Medical credentialing services, from first application to ongoing maintenance
Six service lines, each with its own detailed pages. Everything is included in one engagement; nothing is added on later.
Medicare and Medicaid Enrollment
Government programs are usually the largest payers in a practice and the least forgiving of errors. We file electronically and work every application with the MAC or state agency until approval.
Commercial Insurance Credentialing
We map which plans hold membership in your market, apply to the ones worth joining, and follow each through committee and contracting.
- Insurance credentialing overview
- Aetna, Cigna, UnitedHealthcare, Humana
- Blue Cross Blue Shield, Anthem, Regence
- Tricare East and West
- Contract and fee schedule review
- Regional, exchange and workers compensation networks
CAQH, NPI and Provider Data
The identifiers and profiles every application depends on, set up correctly once and kept aligned across NPPES, PECOS and CAQH.
- CAQH ProView setup and 120-day attestation
- Type 1 and Type 2 NPI registration
- Document collection and verification
- Credentialing audit and expirables management
- Payer directory accuracy checks
- Taxonomy and location alignment
Re-credentialing and Renewals
One calendar for every provider, payer, license and certificate, with renewals completed before anything lapses.
- Commercial re-credentialing every 24 to 36 months
- Medicare revalidation every 5 years
- Medicaid revalidation by state cycle
- License, DEA and CDS renewal tracking via provider licensing
- Malpractice and board certification updates
- Hospital reappointment every 2 years
Verification, Privileging and Compliance
For hospitals, surgery centers and groups that credential their own providers, or want a file that survives a payer audit.
Practice Situations
Credentialing changes with the situation: a new practice, a new hire, a temporary provider or a virtual-only model each need a different sequence.
Payer Enrollment
Enroll with the payers that actually hold share in your market
Every payer runs its own version of credentialing: a different portal, a different data source, a different committee cycle and its own prerequisites. Applying to the wrong plans, or in the wrong order, is the most common way practices lose months. We start with a payer mix analysis for your county, then file every prioritized plan in parallel. Each payer page below explains the route, the typical timeline and the mistakes that get applications returned.
Medicare enrollment
CMS-855I, 855B and 855R filed through PECOS with your MAC
Medicaid enrollment
State fee-for-service plus managed care plans in all 50 states
PECOS enrollment
Account setup, surrogate access and record maintenance
Medicare revalidation
Five-year cycle tracked so billing privileges never deactivate
Medicare Advantage
The MA plans that hold share in your county, enrolled in parallel
Insurance credentialing
Commercial panels from payer selection to signed contract
Aetna
Network interest request, CAQH pull and committee follow-up
Anthem
Elevance Blue plans in 14 states via Availity
Blue Cross Blue Shield
The right Blue licensee for every practice location
Cigna
Medical network plus Evernorth behavioral health
UnitedHealthcare
Request for participation and Optum behavioral enrollment
Humana
Medicare Advantage focused; requires active Medicare first
Tricare
Humana Military East and TriWest West regions
Regence
Blue plans in Washington, Oregon, Idaho and Utah
Practicing in a specific state? Medicaid rules and Blue plans change at every border. See the states we serve for Medicaid, MAC jurisdiction and Blue plan details by state.
How It Works
The credentialing process, step by step
The sequence is the same for every payer and provider type; what changes is which documents and portals each step touches. Nothing is submitted until the file is complete, and nothing is left in a queue without a follow-up date.
Intake and Gap Review
NPI, CAQH and PECOS Setup
NPIs confirmed with the right taxonomy, the CAQH profile built and attested, and PECOS access established before any application goes out.
Verification
Licenses, education, board certification, NPDB and exclusion lists verified at the source to NCQA standards, so problems surface on our desk rather than the committee's. See primary source verification.
Application Submission
Every enrollment is filed in dependency order, Medicare before Medicare Advantage, group before reassignment, with a tracking record for each payer, date and reference number.
Follow-Up and Contracting
Payers are contacted weekly. Development requests are answered the same business day. Contracts are reviewed under payer contracting before you sign.
Effective Date and Maintenance
Provider IDs, effective dates and fee schedules are loaded into billing. Re-credentialing, revalidation and expirables are calendared from day one.
Credentialing guides and standards
Detailed pages on the processes, documents and rules behind every application.
CAQH ProView management
The profile every commercial payer pulls from
NPI registration
Type 1 and Type 2 NPIs with the right taxonomy
Primary source verification
License, education, NPDB and sanction checks
Re-credentialing
Every payer cycle on one calendar
Hospital privileging
Medical staff applications and reappointment
Credentialing audit
Provider by payer status matrix and expirables
Payer contracting
Fee schedules reviewed before you sign
New practice credentialing
Everything in order before opening day
Group practice credentialing
Adding, linking and removing providers
Telehealth credentialing
Licensed and enrolled where the patient is
Credentialing checklist
Every document payers ask for
Locum tenens credentialing
Temporary privileges and Q6 billing rules
Delegated credentialing
Credential once, enroll everywhere
NCQA credentialing standards
What payers verify and how recently
Credentialing cost
Per provider, per payer, no surprises
Credentialing by Provider Type
Enrollment rules change with the license and the setting
A nurse practitioner in a restricted-practice state needs a collaborative agreement on file. A therapist applies to a behavioral health network, not the medical one. A physical therapy clinic enrolls as a group or a rehab agency, and the difference matters. A home health agency needs a certification survey before Medicare will pay a claim. Each provider type page explains the enrollment path, the payer-specific rules and the documents that most often hold things up.
- Physicians (MD and DO)
- Nurse practitioners
- Physician assistants
- Therapists (LCSW, LPC, LMFT)
- Mental health providers and facilities
- ABA therapy and BCBAs
- Dentists and DSOs
- Chiropractors
- Physical therapists
- Occupational therapists
- Substance abuse treatment facilities
- Optometrists
- Podiatrists
- DME and DMEPOS suppliers
- Home health and hospice agencies
- Ambulatory surgery centers
- Urgent care centers
Serving a particular setting? See how we work with private practices, hospitals and health systems, clinics, solo providers, specialty centers, diagnostic labs, urgent care centers and home health and hospice.
Credentialing by Specialty
Specialty programs where credentialing carries extra weight
Some specialties bring requirements that go beyond the standard file: procedure privileges backed by case logs, imaging or laboratory accreditation, state pain clinic licensure, DMEPOS enrollment for dispensing, or a Medicaid-heavy payer mix. These six programs have dedicated credentialing pages, and every one of our 52 specialty billing programs is supported.
Cardiology
Cath lab privileges, imaging accreditation and Medicare Advantage panels
Orthopedics
Surgical privileges, workers compensation and DME enrollment
Dermatology
Closed panel strategy and in-office dermatopathology
Pediatrics
Medicaid, CHIP and Vaccines for Children
OB/GYN
Delivery privileges and Medicaid maternity
Pain management
DEA, state pain clinic licensure and procedure privileges
Family Medicine, Internal Medicine, Psychiatry and Behavioral Health, Psychology and Counseling, Sports Medicine, Neurology, Gastroenterology, Endocrinology, Pulmonology, Rheumatology, Urgent Care, Physical Therapy, Chiropractic, Podiatry, Nurse Practitioners, Physician Assistants, CRNA and Anesthesia, Surgery and Subspecialties, Telemedicine Providers
Timelines and Cost
How long credentialing takes, and what it costs
These are the timelines we typically see for our clients. ClainetRCM has assigned representatives with payers across the United States who help us expedite applications, which is why Medicare, Medicaid and Medicare Advantage enrollments generally close well inside the industry-wide ranges. Incomplete files, missed committee cycles and unanswered development requests are what push a practice past the long end of each range.
| Payer or process | Typical timeline | Most common delay |
|---|---|---|
| Medicare (PECOS) | 30 to 45 days | Forms filed out of sequence; development letters missed |
| State Medicaid and MCOs | 30 to 60 days | Fingerprinting and site visits; MCOs not started in parallel |
| Commercial payers | 90 to 150 days | Unattested CAQH profile; payer not authorized |
| Medicare Advantage plans | 30 to 60 days | Applied before Medicare enrollment was active |
| Hospital privileges | 60 to 90 days | Peer references not returned; privileges beyond training |
| Delegated credentialing (after setup) | About 30 days | Roster errors at submission |
| Re-credentialing | Every 24 to 36 months | Notices sent to a former employee |
Pricing that includes the follow-up
Credentialing is priced per provider per payer for initial applications, or per provider per month for maintenance, re-credentialing and revalidation. Practices that also use ClainetRCM for billing get credentialing bundled at a starting rate of 2.29% of collections, with no setup fee and no long-term contract.
- Weekly payer follow-up through approval, always included
- Development requests and resubmissions at no extra charge
- Contract and fee schedule review before you sign
- Payer application fees passed through at cost and disclosed up front
Why ClainetRCM
What makes our credentialing different
Most credentialing companies submit applications. The difference is what happens in the 90 days after.
Complete files, filed in parallel
Every document is checked against each payer's requirements before submission, and every payer is started at once. The whole set completes in roughly the time the slowest single payer takes.
One coordinator, weekly reporting
A named coordinator owns each provider's file. You get a status report on every open application every week, not a support ticket queue.
Revenue first
We prioritize the payers with the most membership in your county and review every contract against Medicare before you sign, because credentialing exists to enable billing.
All 50 states, every MAC
State Medicaid programs, Medicare Administrative Contractors and Blue plans differ at every border. We know which applies to each of your locations. See states we serve.
Solo to health system
From a single nurse practitioner opening a practice to a delegated credentialing program for a large group, the process scales without a minimum provider count.
HIPAA-compliant and audit-ready
Documents are handled under a signed BAA, files are built to NCQA standards, and every verification carries a date, source and method that satisfies a payer audit.
What we commit to in writing
Things we control and put in your agreement, not performance stats we cannot prove.
Every FileReviewed Document by Document Before Submission
WeeklyPayer Follow-Up and Status Report on Every Application
All 50States We Enroll Providers In
BAASigned With Every Client Before Work Begins
Our commitment to your approval
We do not submit paperwork and disappear. We stay on the file until the effective date is in your billing system, and if a payer asks for more information, we handle it at no extra charge.
- Transparent per-provider, per-payer pricing with no surprise fees
- Pended applications and additional information requests handled, included
- Dedicated credentialing coordinator assigned from day one
- Weekly status updates so you always know where things stand
- Effective dates tracked and every future renewal managed proactively
- HIPAA-compliant document management under a signed BAA
$0 Extra cost if a payer pends your application. We work it until it clears
No commitment required. Response within 24 hours.
Provider FAQs
Provider credentialing questions, answered
Real questions from real providers. If yours is not here, call us.
Medicare enrollment through PECOS typically takes 30 to 60 days. Commercial insurance credentialing runs 90 to 150 days from a complete application to an executed contract, and hospital privileges 90 to 180 days. Because we file every payer at once and follow up weekly, most providers are payable with their key panels within four to five months. Payer-specific timelines are on each page, for example Aetna, UnitedHealthcare and Blue Cross Blue Shield.
Credentialing is the payer's verification of your qualifications. Enrollment is the application that gets you a provider ID with a program such as Medicare or Medicaid. Contracting is the participation agreement and fee schedule that follow. We handle all three, and we review the contract before you sign it; see payer contracting.
State license, DEA and CDS registrations where applicable, board certification, malpractice certificate of insurance, a CV with month and year for every position, NPI confirmation, photo ID, diploma and training certificates, W-9 and a voided check, and hospital privileges or an admitting arrangement where the specialty requires it. The full list by provider type is on our provider credentialing checklist.
CAQH ProView is the shared database that Aetna, Cigna, UnitedHealthcare, Humana, most Blue plans and hundreds of regional payers use to retrieve your credentialing data. It is free for providers, must be re-attested every 120 days, and every payer you apply to must be authorized on it. We build and maintain it as part of every engagement; see CAQH credentialing and profile management.
Medicare allows retroactive billing back to the effective date once enrollment is approved, so held claims can be submitted. Most commercial payers do not, and billing under another provider's NPI is not permitted. We advise on what each of your payers allows while applications are open, and for new practices we sequence everything so you are in network on opening day; see credentialing for a new practice.
Credentialing is priced per provider per payer for initial applications, per provider per month for ongoing maintenance and re-credentialing, or bundled into our billing service at a starting rate of 2.29 percent of collections with no setup fee. Follow-up through approval is always included. The full breakdown is on how much credentialing costs and our pricing page.
Yes. Commercial payers re-credential every 24 to 36 months, Medicare revalidates every five years, Medicaid varies by state and hospitals reappoint every two years. We keep one calendar for every provider and payer, correct the contact information so notices reach us, and complete renewals 90 to 120 days ahead. See re-credentialing services and Medicare revalidation.
Yes. We enroll providers with Medicare, Medicaid and commercial payers in all 50 states and coordinate multi-state licensure through our provider licensing service. Telehealth is billed where the patient is located, so it needs a license and payer enrollment in each of those states; see telehealth credentialing.
Yes. We credential nurse practitioners, physician assistants, therapists, ABA providers, dentists, chiropractors, physical and occupational therapists, optometrists and podiatrists, plus facilities such as ambulatory surgery centers, home health and hospice agencies and substance abuse treatment programs.
We identify the reason, prepare a reconsideration or appeal, and resubmit at no additional charge. Network adequacy denials can sometimes be overturned with evidence of patient demand or a unique service; document problems are fixed and refiled. Most causes of denial, such as work history gaps, expired documents or an unattested CAQH profile, are caught in our pre-submission review, which follows NCQA credentialing standards.
Yes. We provide primary source verification, medical staff credentialing and privileging, expirables tracking and reappointment for hospitals and surgery centers, and we set up and operate delegated credentialing programs for groups and IPAs with the provider volume to qualify.
Ready to stop losing revenue to credentialing delays?
Send us your provider roster and target payers. We will map every gap, tell you which panels are worth the effort, and give you a dated plan. Free, with no commitment.
Free revenue audit
Find out what your practice is losing to denials.
Send us 90 days of remittance data and we will show you, line by line, which claims were underpaid, denied, or never worked, and what it would take to recover them. No cost, no obligation, and you keep the report either way.
No setup fee. No long-term contract. Pricing from 2.29% of monthly collections.