A provider who is not enrolled with a payer cannot bill that payer. Here is how to plan credentialing so new providers and new locations start earning on time.
Hiring a new provider or opening a new location is exciting, but until that provider is credentialed and enrolled with each insurance plan, claims for their visits may be denied or paid out of network. Enrollment can take weeks or months, so planning early matters.
Where the delays come from
- Incomplete applications. A missing document or an unanswered question sends the application back to the start of the queue.
- Out-of-date CAQH profiles. Many commercial payers rely on CAQH ProView; an expired attestation or missing document pauses the review.
- Mismatched information. Names, addresses, NPI and tax ID details must match across every form and system.
- No follow-up. Applications can sit for weeks without anyone checking their status.
A simple plan that works
- Start enrollment as soon as a start date is confirmed.
- Collect licenses, board certifications, malpractice insurance, DEA and work history in one secure file.
- Complete and attest the CAQH profile, then keep it current.
- Submit to every payer the practice works with, including Medicare through PECOS and your state Medicaid program.
- Follow up with each payer on a fixed schedule and record every reference number.
- Track re-credentialing and revalidation dates so active enrollments do not lapse.
Do not forget the details after approval
Once a provider is approved, confirm the effective date, the participating plans and the locations listed. Load this information into your billing system before claims go out.
Healthcare Providers Care handles credentialing and enrollment from start to finish, and new practices get it at a very affordable rate. See our credentialing services.
This article is for general information only and is not legal or compliance advice. Always check the latest guidance from CMS and your payers.