Supporting service
Medical credentialing services and payer enrollment
Medical credentialing is a payer verifying that a provider is qualified to treat its members, and payer enrollment is the setup that lets the provider bill that payer and be paid.
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CAQH asks providers to re-attest every 120 days, and a lapsed profile can hold up credentialing.
Credentialing or enrollment? A provider needs both to be paid.
The two are often said as one, but they are separate steps, and a claim fails if either is missing.
Credentialing
The payer verifies the provider: licences, education, board certification, malpractice insurance and work history, often from the provider’s CAQH profile.
Enrollment
The provider is added to the payer’s plans, under the right practice and tax ID, with an effective date. Only then can claims for that provider be paid in network.
What happens when credentialing slips?
Claims for a provider who isn’t enrolled
A new provider sees patients before their enrollment is effective, and those claims are denied.
Applications that stall
A missing document or a detail that doesn’t match, and an application waits at the payer with nobody chasing it.
A CAQH profile that lapses
CAQH asks providers to re-attest their profile every 120 days, and a lapsed profile can hold up credentialing with the payers that use it.
Re-credentialing missed
Payers re-credential providers on a cycle, and missing the request can take a provider out of network.
Changes nobody reported
A new address, tax ID or group that the payer never heard about, so claims are paid to the wrong place or denied.
How the credentialing process works
Gather the documents
Licences, DEA registration, board certification, malpractice insurance, NPI and the practice’s tax details, collected once and kept current.
Check every detail matches
Names, addresses, NPIs and tax IDs are checked across every application and the CAQH profile before anything is sent.
Choose the payers with you
We agree which payers matter most to your practice and apply to those first.
Apply, and keep CAQH current
Applications go to each payer, and the provider’s CAQH profile is updated and re-attested when it is due.
Follow up until it is approved
Each application is followed with the payer until the provider is credentialed and enrolled, with an effective date.
Track re-credentialing
Expiry dates and re-credentialing cycles are tracked and worked before they come due.
Related billing services
- Eligibility verificationCoverage and benefits checked before the visit, so claims do not fail on eligibility.
- Claims submissionCharges entered, scrubbed and submitted clean, then tracked to a decision.
- Denial managementEvery denial traced to its cause, corrected or appealed, and stopped from repeating.
Credentialing questions
How long does credentialing take?
What do you need from us to start?
Do you handle re-credentialing?
Can you enroll a new provider joining our practice?
Find out whether credentialing is holding up your claims.
Unsure how much revenue you are missing? Start with a complimentary billing audit.
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