Why Credentialing Decides Whether You Get Paid
A clinician can be licensed, board certified and fully booked and still not get paid by an insurer that hasn't credentialed them. Insurance credentialing is how a health plan verifies a provider's qualifications and admits them to its network. Until it is done, claims to that insurer usually come back denied as out of network or "provider not on file," and patients who want to use their insurance book somewhere else.
Credentialing is also slow, paperwork-heavy and easy to stall. One unattested profile or one address that doesn't match another can add weeks. This guide covers what credentialing involves, how long each kind of insurer takes, the documents to gather, the mistakes behind most delays, and what it costs, including what Hero charges.
Credentialing, Contracting and Enrollment Are Three Different Jobs
People use "credentialing" for the whole process of getting on an insurance panel, but it is really three steps, and a provider can finish one without the others. Many insurers combine the first two in a single application. The third is always separate: being in network doesn't mean claims and payments are set up electronically.
| Step | What happens | What you end up with |
|---|---|---|
| Credentialing | The insurer verifies the provider's license, education and training, board certification, DEA registration, malpractice coverage and claims history, usually from the original sources | Approval to join the network |
| Contracting | The provider or group signs the insurer's participation agreement and fee schedule | An effective date, in-network status and contracted rates |
| EDI, ERA and EFT enrollment | The practice's clearinghouse is set up to send claims to the insurer and receive electronic remittances, and payments are set up as direct deposit | Claims, remittances and payments that move electronically |
How Long Credentialing Takes
Plan on about three to four months for most commercial insurers, and longer for some. The clock doesn't start until the insurer has a complete application, so missing documents cost time twice: once to notice and once to resend.
| Insurer | Typical time | What to know |
|---|---|---|
| Medicare | Often about 30 to 60 days for a complete application | Enroll through PECOS. Medicare can allow billing for services up to 30 days before the effective date when circumstances kept you from enrolling earlier. |
| Medicaid | Weeks to several months, by state | Each state runs its own enrollment. Medicaid managed-care plans then credential the provider separately. |
| Commercial plans | Commonly 60 to 120 days, sometimes longer | Most read the provider's CAQH ProView profile. Some panels are closed in some areas and specialties. |
| Medicare Advantage | Same as commercial plans | Each plan credentials providers for its own network. Enrollment in Medicare does not make a provider in network with a Medicare Advantage plan. |
Start before you need it. When a new provider has a start date, begin credentialing 90 to 120 days before their first day with patients. When you're opening a practice, start as soon as you have a practice address, a tax ID and malpractice coverage.
The Credentialing Process, Step by Step
1. Gather the documents once
Every insurer asks for nearly the same information. Collect it once, check that it agrees everywhere, and keep it current. The checklist below covers what most insurers ask for.
2. Complete and attest the CAQH ProView profile
CAQH ProView is a free profile that most commercial insurers read instead of collecting everything themselves. Fill it in completely, upload the supporting documents, give each insurer you apply to permission to view it, and attest that it is accurate. Attestation lapses after 120 days, and an insurer can't use a lapsed profile, which is one of the most common reasons an application stalls.
3. Choose insurers and submit the applications
Start with the insurers your patients actually carry. Ask the front desk which plans callers mention, or look at the payer mix of the practice the provider is joining. Medicare enrollment goes through PECOS, Medicaid through each state's provider portal, and commercial insurers through their own portals or forms. A provider joining a group must be linked to the group's tax ID and group NPI, not only enrolled as an individual.
4. Follow up until the insurer decides
Applications don't move on their own. Insurers ask for missing items by fax, email or portal message, and a request that goes unanswered can close the file. Check status on a schedule, answer requests the same week, and keep a record of every reference number and contact.
5. Sign the contract and record the effective date
Approval leads to a participation agreement and fee schedule. Read the fee schedule before you sign it. Once it is signed, record the provider's effective date and any provider ID the insurer assigns, because claims for visits before the effective date may not be paid.
6. Set up electronic claims and payments
Finally, enroll for electronic claims (EDI), electronic remittances (ERA) and direct deposit (EFT) with the insurer through your clearinghouse. Without this step, an in-network provider can still end up with rejected claims or paper checks.
Credentialing Document Checklist
- NPI numbers: an individual (Type 1) NPI for each provider and an organizational (Type 2) NPI for a group, with the NPPES record current
- State licenses for every state where your patients are, including telehealth patients
- DEA registration, and a state controlled-substance registration where your state requires one
- Board certification, or diplomas and residency or fellowship certificates
- Malpractice insurance certificate with coverage limits and dates, plus claims history
- CV with month-and-year work history for at least five years, with any gaps explained
- Hospital privileges or an admitting arrangement, if the insurer requires one
- Practice tax ID with the IRS confirmation letter, and a W-9
- Practice locations: addresses, phone numbers, hours and the services offered at each
- CLIA certificate if you run lab tests in the office
- Bank letter or voided check for direct deposit
- Ownership and managing-employee details for Medicare and Medicaid applications
What Slows Credentialing Down
Most delays come from a small number of avoidable problems:
- A lapsed CAQH attestation, or an insurer that hasn't been authorized to view the profile.
- Information that doesn't match. The practice address, specialty (taxonomy) and name on the application should match the NPPES record, the license and the CAQH profile. Insurers check, and a mismatch sends the file back.
- Unexplained gaps in work history. Insurers expect an explanation for gaps of more than a few months.
- Documents that expire mid-application, most often a malpractice certificate or a license renewal.
- A missing group link. An individual approval doesn't help if the provider isn't linked to the group's tax ID that the claims go out under.
- No follow-up. An unanswered request for one more document can close the application, and the clock starts over.
- Closed panels. Some insurers aren't adding providers in a given area or specialty. You can ask for an exception, apply later, or see those patients out of network.
Seeing Patients While Credentialing Is Pending
A new provider rarely waits for every insurer before opening the schedule. Practices usually do one of three things: book insured patients only after the expected effective date, see them as self-pay with the cost explained up front, or see them and hold the claims until the insurer recognizes the provider.
Holding claims is better than sending them early. A claim sent before the provider is on file comes back denied, and working that denial later takes more time than waiting. When you bill through Hero, claims to an insurer that is still credentialing a provider can be held instead of sent. Hero keeps reading that insurer's answers to the practice's eligibility checks, and once the insurer recognizes the provider, the held claims are released.
A held claim isn't a covered claim. Medicare can allow billing for services up to 30 days before the effective date when circumstances kept you from enrolling earlier, but many commercial insurers pay only from the effective date forward. Tell patients when a visit before the effective date may not be covered.
Keeping Credentials Current
Credentialing isn't a one-time event. Each of these keeps a provider in network:
- Re-attest CAQH every 120 days, and update it whenever a license, DEA registration or malpractice policy renews.
- Recredentialing: commercial insurers typically recredential providers at least every three years.
- Revalidation: Medicare and Medicaid require revalidation at least every five years.
- Report changes promptly. A new address, a new location, a new tax ID or a provider leaving must be reported to each insurer, and Medicare sets deadlines as short as 30 days for some changes.
What Credentialing Costs
Most insurers don't charge physicians or other individual clinicians an application fee. The real cost is time: preparing each application, keeping the CAQH profile current, answering requests and following up for months. A practice can do this in-house, or hire a credentialing service, which usually charges per application or a monthly fee per provider.
Hero's credentialing is $200 per insurer. Practices that sign up for Hero EMR get 50% off, so it is $100 per insurer. For that, we:
- gather the provider's documents once and use them for every insurer;
- bring the CAQH profile up to date and complete each insurer's application;
- submit the application and follow up with the insurer until it decides;
- for practices on Hero EMR, connect the result to billing, so claims to an insurer that hasn't finished wait instead of being denied.
No one can guarantee that an insurer will accept a provider, and we don't either. Some panels are closed, and the decision is the insurer's. Credentialing is priced separately from the EMR subscription; see every Hero price on the pricing page.
Frequently Asked Questions
How much does insurance credentialing cost?
Most insurers don't charge physicians or other individual clinicians an application fee, so the cost is the time it takes to prepare, submit and follow up on each application. Outside credentialing services charge per application or a monthly fee per provider. Hero charges $200 per insurer, and practices that sign up for Hero EMR pay half, $100 per insurer.
How long does credentialing take?
Plan on about three to four months for most commercial insurers, and longer for some. Medicare is often faster for a complete application, and Medicaid varies by state. Start 90 to 120 days before a provider's first day with patients.
Do I need Hero EMR to use Hero's credentialing?
No. Credentialing is $200 per insurer on its own. Practices that sign up for Hero EMR get 50% off, so it is $100 per insurer.
What is CAQH ProView and do I need it?
CAQH ProView is a free online profile where providers store their credentialing information once for many commercial insurers to read. Most commercial insurers require it. You must re-attest that the profile is accurate every 120 days, or insurers can't use it.
Does Medicare enrollment cover Medicare Advantage plans?
No. Medicare Advantage plans are run by private insurers, and each one credentials providers for its own network. A provider enrolled in Medicare still needs to be credentialed with each Medicare Advantage plan to be in network.
Can I bill for visits before I'm credentialed?
It depends on the insurer. Medicare can allow billing for services up to 30 days before the effective date when circumstances kept you from enrolling earlier. Many commercial insurers pay only from the effective date forward. Hold claims until the insurer recognizes the provider, and tell patients up front when a visit may not be covered.
How often do providers need to be recredentialed?
Commercial insurers typically recredential at least every three years. Medicare and Medicaid require revalidation at least every five years, and CAQH profiles need re-attestation every 120 days.
Get credentialed while you set up Hero
Book a demo and we'll go through the insurers your patients carry and what credentialing would cost your practice: $200 per insurer, or $100 with Hero EMR.
Book a Demo See Pricing