Getting paid starts long before your first claim. Medical credentialing and payer enrollment are the gatekeepers to network participation, referrals, and steady cash flow. This guide walks you through each stage—from NPI and CAQH to Medicare PECOS and commercial contracts—plus how Next RCM’s Credentialing Services streamlines the process so you can start seeing patients sooner.
Why credentialing and payer enrollment matter
- Faster revenue start: No enrollment = no in-network payment.
- Referral access: Health systems and plans prefer in-network providers.
- Compliance & risk control: Primary-source verification (PSV) protects your brand and patients.
- Operational clarity: Clean rosters reduce claim rejections tied to NPI/taxonomy or outdated addresses.
Next RCM treats credentialing as a revenue project, not just paperwork—clear timelines, proactive follow-ups, and payer-specific checklists.
Step-by-step: from “hired” to “in-network”
1) Map your footprint and timelines
List every location, TIN, and specialty you’ll bill under. Decide which payers matter for your market. Typical timelines range from 30–120+ days depending on payer and state.
Next RCM builds a payer roadmap with target dates and dependencies, so nothing stalls.
2) Get (or validate) NPIs and taxonomy
- Type 1 NPI for individual providers.
- Type 2 NPI for organizations under each TIN.
Confirm taxonomy codes that match your specialty and billing intent.
3) Collect core documents (one clean packet)
- CV with month/year format and no gaps
- State license(s), DEA (if applicable)
- Board certification, hospital privileges (or admitting plan)
- Malpractice face sheet and claims history
- Government ID, SSN/EIN, W-9
- Practice addresses, phone/fax, billing service info, hours, languages
- Ownership/management details (as required)
Pro tip: Use a single, shared folder. Next RCM maintains a master packet so updates flow to every payer at once.
4) Build and attest CAQH ProView
Most commercial payers pull provider data from CAQH. Complete all sections, upload documents, and attest. Set reminders to re-attest when prompted.
Next RCM keeps CAQH current, so payer pulls don’t fail for expired docs.
5) Medicare enrollment (PECOS)
Enroll or update via PECOS with the correct enrollment type (individual/group) and practice locations. Ensure reassignments are signed so payments route to the right TIN.
6) Medicaid (state) enrollment
Follow state-specific requirements (background checks, site visits, specialty proofs). Align taxonomy and locations with your Medicare and commercial profiles.
7) Commercial payers: applications & contracts
Submit applications (often triggered by CAQH pulls). Track credentialing committee dates and contracting steps. Review fee schedules and effective dates before signing.
Next RCM sequences submissions so you’re not waiting on the slowest payer to start seeing patients.
8) Hospital privileges or covering plans
If your specialty needs admitting privileges, secure them early. If not, document your admitting arrangement or covering plan per payer policy.
9) Primary-source verification (PSV) & background checks
Payers verify licenses, education, sanctions, malpractice history, OIG/NPDB, and more. Missing data here is the #1 reason files stall.
We chase verifications, respond to payer “pend” requests, and escalate when timelines slip.
10) Effective dates, rosters, and go-live checks
Confirm effective dates, participation status, and contracted specialties/locations. Update PM/EHR, clearinghouse, websites, and payer directories. Run test claims.
Next RCM closes the loop with a go-live checklist and keeps a living roster for future updates.
What slows credentialing and how to avoid it
- Document gaps: Missing malpractice claims history or month/year CV timelines.
- CAQH not attested: Payers can’t pull stale profiles.
- Address/NPI mismatches: One character off can derail a file.
- Privilege issues: Lack of hospital privileges (or no covering plan).
- Payer backlog: Committees meet monthly/quarterly; expect delays without follow-up.
Fixes: centralized document control, weekly status checks, and a single source of truth for addresses/NPIs/taxonomies. That’s built into Next RCM’s Credentialing Services.
Recredentialing, revalidation, and maintenance
Credentialing isn’t “set and forget.”
- Recredentialing: typically every 2–3 years for commercial plans.
- Medicare/Medicaid revalidation: periodic; watch your MAC/state notices.
- Directory accuracy: update when providers, locations, or hours change.
- CAQH attestations: complete promptly to avoid network suspensions.
- Roster management: add/suspend/terminate providers the moment a status changes.
Next RCM manages calendars and notices, so you don’t miss a deadline.
Group types & special cases
- Multi-specialty groups: multiple taxonomies, place-of-service types, and fee schedules.
- Telehealth: confirm service states, licensing, and payer telehealth policies.
- New sites or relocations: amend contracts and directory data before claims go out.
- Allied professionals (PT/OT/SLP/NP/PA): payer-specific supervision and enrollment rules.
- DMEPOS or ancillary services: extra certifications and site criteria may apply.
Credentialing vs. contracting (know the difference)
- Credentialing: verifies the provider’s qualifications.
- Contracting: negotiates rates and sets participation.
A clean credentialing file speeds contracting; a signed contract without valid credentialing won’t pay.
Next RCM coordinates both tracks so effective dates and fee schedules line up.
Go-live checklist (print and use)
- ✅ Effective dates confirmed for each payer
- ✅ Contracted specialties, locations, and TINs verified
- ✅ PM/EHR and clearinghouse IDs updated (payer IDs, NPIs, taxonomies)
- ✅ Staff trained on eligibility/authorization and new payer rules
- ✅ Website/Google Business/Provider directories updated
- ✅ Test claims submitted and acknowledged
KPIs for credentialing & enrollment
- Days to participation (per payer)
- Files pending >30/60 days (with reason)
- First-pass participation accuracy (no returned claims for ID/taxonomy errors)
- Directory accuracy rate (no patient access complaints)
- Renewal on-time rate (recredentialing/revalidations)
Next RCM reports these KPIs monthly so you can spot bottlenecks early.
How Next RCM’s Credentialing Services help
- Payer roadmap & timelines aligned to your market strategy
- Document wrangling & CAQH management with proactive attestations
- Medicare PECOS & Medicaid applications and follow-ups
- Commercial payer submissions, contracting support, and committee tracking
- Roster maintenance for adds/terms/location changes
- Escalation & issue resolution when a file stalls
You get a single point of contact, weekly status updates, and a clean handoff to billing when effective dates land.
FAQs
How long does medical credentialing take?
It varies by payer and state. Many commercial plans complete credentialing in 60–120 days; some faster, some slower. Medicare timelines depend on MAC workloads and completeness.
Can we start billing out-of-network while we wait?
Sometimes, but patient responsibility can be higher and payment less predictable. Confirm policies before scheduling high-cost services.
What’s the fastest way to speed enrollment?
A complete, consistent packet; up-to-date CAQH; accurate NPIs/taxonomies; and weekly follow-ups. Next RCM handles all four.
Do we need hospital privileges?
Depends on your specialty and payer policy. If not required, document an admitting or coverage plan.
What if a provider leaves or moves?
Update rosters and directory data immediately. Term old payers and enroll new ones so claims don’t bounce.
Conclusion
Medical credentialing and payer enrollment are the launchpad for revenue—not just a compliance exercise. With the right sequence, documents, and follow-through, you’ll shorten the gap between hiring and getting paid. If you want a partner that owns the timeline and the details, Next RCM’s Credentialing Services can get you in-network—then keep you there.
Ready to go in-network faster? Book a meeting with Next RCM and get a payer roadmap tailored to your specialties and locations.
