Provider credentialing
Provider credentialing is the process of enrolling a provider or group with each payer so claims can be submitted and paid under an active, in-network status.
The first step in the cycle. Feeds into patient scheduling.
Where practices lose money here
Enrollment gaps delay billing
A provider who sees patients before enrollment finishes cannot bill those visits under an in-network rate, and some payers will not backdate at all.
Revalidation deadlines get missed
Payers require periodic revalidation. Missing a window can suspend a provider from a panel with no warning until claims start bouncing.
CAQH profiles go stale
An expired CAQH attestation is one of the most common reasons a clean enrollment application gets kicked back for correction, adding weeks.
How we handle it
Maintain and re-attest the CAQH profile on the payer-required cycle, with document expirations tracked on a calendar rather than discovered after the fact.
Submit and track payer enrollment applications individually, with expected timelines of 60 to 120 days per payer depending on the plan.
Handle both group and individual provider enrollment, matching the structure the practice actually bills under.
Confirm effective dates in writing and pursue retroactive billing where the payer allows it, so visits seen during processing are not written off.
Run a revalidation calendar across every payer contract so re-credentialing starts before the deadline, not after a rejection.
Flag panel closures and alternate enrollment paths when a payer is not accepting new providers in a given specialty or region.
What you receive
Concrete output for this step, delivered on a set schedule rather than on request.
- A credentialing status tracker showing every payer, application stage, and expected effective date.
- Copies of enrollment confirmations and effective date letters as they are received.
- A revalidation calendar covering the next 24 months.
Where this sits in the cycle
Credentialing is the entry point to the revenue cycle. Nothing downstream, scheduling, registration, claim submission, works correctly for a payer the provider is not enrolled with.
Questions about this step
How long does enrollment actually take?
Most commercial payers run 60 to 90 days from a complete application. Medicare and Medicaid can run 90 to 120 days depending on the state and specialty.
Can we bill for visits seen while enrollment is pending?
Sometimes. Many commercial payers allow retroactive billing to the application date once approved. Medicare has its own retroactive billing rules by provider type. We pursue this on every application where it is available.
Do you handle both new providers and revalidations?
Yes. New enrollment and ongoing revalidation are both part of the standard engagement.
Want us to review how this is handled in your practice right now?
The free billing audit looks at provider credentialing alongside the rest of the cycle, and comes back with specific findings.