To get credentialed with insurance companies as a practice, you set up the business identity first (tax ID and an organizational NPI), get each provider's own NPI, license and CAQH profile in order, then enroll the group and every provider with each payer: Medicare through PECOS, your state Medicaid program and its managed care plans, and each commercial plan, which also means signing a contract. The order matters, because each step needs the one before it.
Step 1: set up the practice's identity
- Legal entity and tax ID (EIN). Payers pay the entity on its tax ID, and every application asks for it.
- Organizational (Type 2) NPI from NPPES, with the exact legal name and practice address you will use everywhere else.
- Practice location ready. Many applications need a service address, and Medicare's effective date can depend on when you started furnishing services at that location.
- A business bank account for electronic funds transfer, so payments do not stall after approval.
Step 2: get each provider ready
- Individual (Type 1) NPI.
- Active state license, and any controlled-substance registrations prescribers need.
- Malpractice coverage and a current certificate of insurance.
- A complete CAQH ProView profile, attested. CAQH requires re-attestation every 120 days (every 180 days in Illinois).
- Work history, education and hospital affiliations, with gaps explained.
Step 3: enroll with each type of payer
| Payer | What enrollment involves |
|---|---|
| Medicare | Enroll the group and each individual provider (online through PECOS is fastest), and reassign each provider's benefits to the group so payment goes to the practice. |
| State Medicaid | Enroll with the state program. Federal rules require states to screen and enroll every network provider of their Medicaid managed care plans, so state enrollment is usually needed even if you only plan to see managed care patients. |
| Medicaid managed care plans | Each plan credentials and contracts with you separately, after or alongside state enrollment. |
| Commercial plans | Each plan verifies credentials (usually from CAQH) and offers a contract with a fee schedule. Credentialing alone does not make you in network; the signed contract and a confirmed effective date do. |
Step 4: confirm, connect and calendar
- Confirm each effective date in writing, per payer and per provider.
- Load the payers into your billing system with the right group and individual numbers.
- Set up electronic remittance and electronic funds transfer with each payer, so payments and explanations of benefits arrive electronically.
- Calendar every renewal: CAQH re-attestation, licenses, malpractice, Medicare revalidation every 5 years and commercial re-credentialing.
Free credentialing for 3 insurance payers for new billing clients.
Claim Your Free CredentialingWhich payers to start with
Start with the plans your patients actually carry, not the longest list. For a new practice, look at the payer mix of the community you serve or of the patients following a provider from their old job. Ask each commercial plan whether its network is open for your specialty and area before you invest in the application.
Common mistakes when getting credentialed
- Seeing patients before effective dates, then discovering the claims cannot be paid in network.
- Credentialing providers individually but never linking them to the group, so claims pay to the wrong tax ID or deny.
- Using slightly different names or addresses across NPPES, CAQH and applications.
- Assuming credentialing approval means a contract is signed.
- Letting CAQH attestation lapse while applications are pending.
- Skipping state Medicaid enrollment and then being unable to join Medicaid managed care networks.
How long it takes
Medicare publishes processing standards for its contractors; most other payers do not. Our guide to how long insurance credentialing takes covers the numbers CMS publishes and what slows commercial applications.
How Sterling Global Solution LLC credentials new practices
We set up the order of operations with you, collect and check every document once, build and attest CAQH, file the Medicare group and individual enrollments, enroll with your state Medicaid program and its plans, submit each commercial application, and follow up until every effective date is confirmed in writing. Then we load the payers, set up electronic remittance and keep the renewal calendar. New billing clients get credentialing with 3 insurance payers free. See our free credentialing offer, our credentialing services, and the guide for therapists.
Frequently asked questions
How do I get credentialed with insurance companies?
Is credentialing the same as being in network?
Do I need to enroll in state Medicaid to join Medicaid managed care plans?
What does a new practice need before credentialing?
Do you offer free credentialing for new practices?
Sources
Code of Federal Regulations, 42 CFR 438.602(b): states must screen and enroll all network providers of Medicaid managed care plans.
Code of Federal Regulations, 42 CFR 424.520(d): Medicare effective date of billing privileges.
CAQH, CAQH ProView Quick Reference Guide for Providers: re-attestation every 120 days, 180 days in Illinois.
Centers for Medicare & Medicaid Services, NPPES and Medicare Program Integrity Manual, chapter 10.
Medicaid and commercial requirements vary by state and plan. How we verify this guidance.
Related reading
- How long does insurance credentialing take?. Medicare processing standards and what slows other payers.
- Credentialing services for therapists. The steps for therapists and counselors.
- Private practice billing services. Billing once you are in network.
- Provider credentialing & payer enrollment. Our full credentialing service.
- Medicare credentialing services. The Medicare forms and timelines in detail.
Get your practice in network
Free credentialing for 3 insurance payers for new billing clients.
Claim Your Free CredentialingNo setup fee. No long-term contract.