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Provider Credentialing FAQs

Find answers to common questions about credentialing, enrollment, and our services. Can't find what you're looking for? Contact us anytime.

General Credentialing Questions

What is provider credentialing?

Provider credentialing is the process of verifying a healthcare provider's qualifications, education, training, licensure, and professional background to ensure they meet the standards required by insurance companies, hospitals, and regulatory bodies. Without it, providers cannot bill insurance companies or receive reimbursements — making it the critical foundation of any practice's revenue cycle.

Why is credentialing so important?

Without proper credentialing, providers cannot bill insurance companies, receive reimbursements from Medicare/Medicaid, admit patients to hospitals, or participate in insurance networks. Each uncredentialed provider costs practices $10,000—$15,000 per month in lost revenue, creates compliance risks, and limits patient access to care. Credentialing also protects patients by ensuring only qualified professionals provide care.

How long does provider credentialing take?

The industry standard is 90—120 days for commercial insurance and 60—90 days for Medicare. Our average is 45—60 days due to our streamlined process, direct payer relationships, and proactive 5—7 day follow-up cadence. Complex cases may take longer depending on the payer and any issues discovered during verification.

What documents are needed for credentialing?

Typical requirements include: Current CV/resume, medical school diploma, residency/fellowship certificates, board certifications, state medical licenses, DEA certificate, malpractice insurance declarations page, professional references, work history, photo ID, Social Security card, and Medicare/NPI numbers. We'll send you a comprehensive personalized checklist during onboarding.

What is primary source verification (PSV)?

Primary Source Verification (PSV) means verifying credentials directly from the original issuing source — like contacting the medical school, state licensing board, or certifying body directly — rather than simply accepting copies of documents. PSV is required by all payers and accrediting organizations to ensure the authenticity of credentials.

What is CAQH ProView?

CAQH (Council for Affordable Quality Healthcare) ProView is a centralized database where providers enter their credentialing information once and authorize multiple insurance companies to access it — reducing duplicate paperwork and accelerating credentialing. Over 1,500 health plans use CAQH, making it an essential component of efficient multi-payer enrollment.

How much does credentialing cost?

Our transparent pricing starts at $250 per Medicare/Medicaid application and $300 for commercial insurance — with no hidden fees. Monthly maintenance plans start at $199/month for solo providers. Credentialing typically pays for itself within the first month once providers are approved and billing begins. We provide a custom quote during your free consultation.
Re-Credentialing Questions

What is re-credentialing and when is it required?

Re-credentialing is the periodic reverification of a provider's credentials required by insurance companies and hospitals — typically every 2—3 years — to ensure continued compliance and network participation. It's essentially a renewal of your credentialing status with each payer.

What happens if I miss a re-credentialing deadline?

Missing re-credentialing deadlines can result in: temporary suspension from insurance networks (during which you cannot bill), loss of patient access, needing to complete full initial credentialing again, thousands in lost revenue, and potential compliance violations. We start tracking your deadlines 180 days in advance to ensure this never happens.

How far in advance should I start re-credentialing?

We recommend starting at least 120—180 days before your expiration date to guarantee no coverage gaps. Our systems automatically alert clients at 90, 60, and 30 days before deadlines, and we begin the re-credentialing process at the 90-day mark to provide adequate time for payer processing.
Medicare & Medicaid Questions

What is PECOS and do I need it?

PECOS (Provider Enrollment, Chain, and Ownership System) is CMS's online system for Medicare enrollment. Any provider or organization wishing to bill Medicare must be enrolled in PECOS. It's required for all Medicare participating providers, ordering/referring providers, and suppliers of durable medical equipment.

How often must I revalidate Medicare enrollment?

Medicare requires revalidation every 5 years at minimum — sooner if significant practice information changes. Missing revalidation deadlines can result in deactivation of billing privileges. CMS sends notices in advance, but we track all revalidation dates for our clients proactively.

Can I bill Medicare while my enrollment is pending?

No. You must receive an official effective date and billing privileges from CMS before submitting Medicare claims. However, in some cases you may be able to retroactively bill once approved — depending on your situation. We guide clients through this process and help maximize the lookback period where possible.

Is Medicaid enrollment different in each state?

Yes. Each state manages its own Medicaid program with unique requirements, application forms, processing times, and renewal cycles. We maintain expertise in all 50 state Medicaid programs and handle enrollment in any state where your patients are located — critical for telehealth and multi-state practices.
Hospital Credentialing Questions

Is hospital credentialing different from insurance credentialing?

Yes, significantly. Hospital credentialing (also called medical staff credentialing) is more rigorous and facility-specific. It includes privilege delineation (defining exactly what procedures you can perform), peer references, committee review, and board approval — in addition to standard credential verification. It's a separate process from insurance/payer enrollment.

What are clinical privileges?

Clinical privileges define the specific procedures, treatments, and services a provider is authorized to perform at a particular hospital or facility — based on their training, experience, and demonstrated competency. Privileges are granted by the hospital's medical staff committee and are facility-specific (you may need separate privileges at each hospital).

How long does hospital credentialing take?

Typically 60—120 days depending on the hospital's credentialing committee meeting schedule, the completeness of your application, and whether any issues arise during verification. Many hospitals only hold credentialing committee meetings monthly, which can extend timelines. We prepare complete, accurate applications to avoid delays.
Telehealth Credentialing Questions

Do I need separate credentialing for telehealth patients in other states?

Yes. When practicing telemedicine across state lines, you need active licensure in the state where the patient is physically located at the time of the visit — not just where you're located. This means multi-state licensing and, in most cases, payer credentialing in each state as well. We coordinate multi-state credentialing routinely.

What is the Interstate Medical Licensure Compact (IMLC)?

The IMLC is an agreement among participating states that streamlines the medical licensing process for physicians who want to practice medicine in multiple states. Rather than applying to each state separately, eligible physicians can apply once through the IMLC to receive licenses in multiple member states simultaneously. Currently 40+ states participate. We handle IMLC applications as part of our telehealth credentialing service.
About Our Services

What makes your credentialing service different from others?

Key differentiators: 50% faster processing (45 days vs. 90+ industry standard), dedicated credentialing manager per client (not a shared pool), real-time tracking portal, 98% first-time approval rate, transparent pricing with no hidden fees, comprehensive expirables management, and integration with RCM services. We also handle complex cases that other companies refuse.

Can you help if my credentialing application was denied?

Absolutely. We specialize in complex cases, including prior denials, malpractice history, board issues, and unusual circumstances. Our former payer employees understand exactly what's needed to resolve the underlying issues and successfully resubmit. We've helped many providers navigate situations that other credentialing companies refused to take on.

How do I get started?

Schedule a free 30-minute consultation via our contact form or call us directly at (800) 555-1234. We'll assess your needs, answer all your questions, provide a custom quote, and outline exactly what to expect. We can begin immediately upon receiving your signed agreement — often within 24 hours.

Do you credential all types of providers and specialties?

Yes. We credential physicians (all specialties), nurse practitioners, physician assistants, clinical nurse specialists, physical therapists, occupational therapists, speech therapists, psychologists, psychiatrists, licensed counselors, social workers, DME suppliers, laboratories, imaging centers, ambulatory surgery centers, urgent care clinics, and facilities. All 45+ medical specialties covered.

What payment terms do you offer?

We offer flexible options: per-application billing (paid upfront or net-15), monthly subscription plans (auto-payment starting at $199/provider/month), and annual packages with discounted pricing. For RCM services, we typically work on a percentage of collections (5—7%). We accept all major credit cards, ACH, and check.

Are you HIPAA compliant? How do you protect our data?

Yes, absolutely. We maintain full HIPAA compliance including: end-to-end AES-256 encryption for all data, HIPAA-compliant cloud infrastructure, strict role-based access controls, comprehensive audit logging, signed BAAs with all clients, annual HIPAA training for all staff, and zero data breach history. Your sensitive provider information is always protected.
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