If you plan to treat Medicare or Medicaid patients, you must clear every CMS credentialing requirement first. Skip a step and you risk landing on the dreaded “red list,” which means zero reimbursement. Relax, though: credentialing is not rocket science. Think of it as brewing your morning coffee—simple, but you still need the right steps.

In this guide, you will learn about:

• Provider enrollment basics (PECOS, CMS-855I, CMS-855B)
• Medicare and Medicaid credentialing checklists
• Telemedicine credentialing rules for virtual visits
• Delegated credentialing and how large groups speed things up

As a medical billing specialist, I have helped thousands of clinics move from pending to paid status without a single denial. You can do the same. Follow along and see how to:

• Build a spotless CAQH profile
• Avoid common credentialing denials
• Keep your NPI linked to the correct taxonomy code
• Meet every re-credentialing deadline

Have questions like “How do I join Medicare as a new provider?” or “What is the fastest way to update PECOS?” They are answered here. By the end, you will know exactly what CMS expects, which forms to file, and how to stay on the green list so your healthcare claims get paid in full and on time.

CMS Credentialing Requirements for Healthcare Providers in the USA

CMS (Centers for Medicare & Medicaid Services) credentialing requirements refer to the processes and standards that healthcare providers must meet in order to be approved for participation in Medicare and Medicaid programs. 

Some of the basic requirements are:

1). Obtain Your National Provider Identifier (NPI)

The initial step in the CMS credentialing process is obtaining your NPI number. It is a 10-digit identifier utilized for all healthcare billing, including payment for Medicare and Medicaid. You will not be able to send in or get reimbursed for any claims if you do not have it.

Application for your NPI is possible through the National Plan and Provider Enumeration System (NPPES). The application involves basic information such as your name, practice address, tax ID, contact information, license, and credentials.

The majority of healthcare professionals register for the NPI first, since they will also require it during later PECOS registration and CMS enrollment.

Having an NPI is among the most usual prerequisites for any medical billing operation. It ensures that CMS and payers are able to track who is offering the services, particularly for specialties such as family medicine, behavioral health, or physical therapy.

2). Ensure Your License is Current and Validated

You will need a current and unrestricted license to practice in the state in which you will be treating patients. CMS will not accept an expired or restricted license, and they will check for this information when you are enrolling.

Depending on your provider type, you may also be asked to furnish proof of board certification or further training. For instance, some positions, such as cardiologists or nurse anesthetists, will require additional credentials.

The CMS also cross-checks the Office of Inspector General (OIG) List of Exclusions. In case you have participated in healthcare fraud, abuse, or other disqualifying conduct, you will be excluded from participation in Medicare. This is done to make sure that nothing but eligible health care providers are permitted to charge Medicare and Medicaid.

3). Fill out the CMS Enrollment Forms or Use PECOS

Once your licensure and NPI are verified, the following step is to formally enroll in Medicare. You may do this by filing the respective CMS-855 form or by enrolling online through PECOS, or Provider Enrollment, Chain, and Ownership System.

Every form has a particular function:

• Individual healthcare providers, such as physicians, therapists, and nurses, use CMS-855I.
• The CMS-855B is utilized for group practices and clinics.
• CMS-855A is for institutional providers, including hospitals and nursing facilities.
• CMS-855R is for reassigning Medicare benefits to an entity, such as a group or an organization.

PECOS is the most popular choice among providers as it enables quicker submission and immediate tracking of application status. Filing the incorrect form or omission of documentation will hold up your credentialing process by a great deal, hence you need to do this step with care.

4). Credentialing by a Medicare Administrative Contractor (MAC)

During CMS enrollment, every provider passes through a Medicare Administrative Contractor for review. A MAC is a private firm that manages Medicare enrollment, handles claims processing, and verifies provider credentials within its region.

A MAC checks your forms, confirms your license, and makes sure every supporting document is in place. If something is missing, you receive a request for more information instead of a flat denial. Processing times vary by region, so keep local timelines in mind.

When the MAC approves your file, CMS issues a Provider Transaction Access Number (PTAN). You will need this PTAN whenever you submit Medicare claims or update your record in PECOS.

Smooth MAC credentialing sets the stage for trouble-free billing with Medicare beneficiaries.

5). Medicare Participation Agreement

After credentialing, CMS asks you to sign a Medicare Participation Agreement. This short contract spells out what you agree to when you treat Medicare patients.

• You follow all CMS regulations, including coding rules, reimbursement limits, and fraud-prevention policies.
• You accept the Medicare fee schedule as full payment, except for allowed coinsurance or deductibles.
• You send clean claims on time and bill only for medically necessary services.
• You maintain quality-of-care standards, which CMS may audit through its quality reporting programs.

Once the agreement is on file, you can begin seeing Medicare patients and submitting electronic claims without delay.

6). Ongoing Compliance with Federal and State Rules

CMS approval is not the finish line. Providers must stay current with both federal regulations and state requirements to keep billing privileges active.

➜ Federal rules

• Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• HIPAA privacy and security safeguards
• Policies in the Affordable Care Act that affect provider enrollment
• Current CMS billing and coding guidelines

These standards apply to physicians, therapists, hospitals, home health agencies, and every other Medicare-enrolled entity.

➜ State rules

• Professional licensure laws require an active, unrestricted license in each state where you practice.
• Scope-of-practice statutes limit which services your license allows you to perform.
• Each state Medicaid program has its own enrollment steps that build on federal guidance.
• Managed Care Organizations (MCOs) may add extra credentialing checks before they will contract with you.
• State privacy laws, such as California’s CCPA, can be stricter than HIPAA.
• If you deliver telehealth, you must follow every state’s telemedicine and cross-state licensure rules.

Meeting these federal and state obligations helps you avoid claim denials, overpayment recoupments, and potential exclusion from government programs.

7). Clear Background Check

CMS only accepts providers whose records are clean. During both initial credentialing and the three-year recredentialing cycle, CMS runs a background check that looks at professional qualifications, criminal history, and any past Medicare fraud or abuse. Failing this review can delay or deny enrollment, revoke billing privileges, and trigger legal or financial penalties.

What CMS reviews:

• Criminal convictions at the federal or state level
• Medicare and Medicaid exclusion lists
• License status plus any disciplinary actions
• Malpractice claims and settlements
• Education, training, and residency verification

8). Malpractice Insurance Requirements

Every provider must carry active malpractice (professional liability) insurance to protect patients and themselves against errors or negligence claims. CMS checks coverage at enrollment, at recredentialing, and during random audits.

• Most plans require at least one million dollars per claim and three million dollars aggregate each year, although limits can vary by state or specialty
• A current Certificate of Insurance (COI) must list the insured name, policy number, coverage dates, limits, and carrier
• Providers changing jobs or retiring may need tail coverage to insure prior acts

Without proof of adequate coverage, CMS can deny enrollment or terminate participation.

9). Meeting CMS Quality Standards

CMS expects all enrolled professionals and facilities to deliver safe, effective, and high-quality care. Compliance is also tied to value-based payment models.

Key quality checkpoints:

• Adhering to Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• Reporting through MIPS if eligible
• Tracking and submitting Clinical Quality Measures (CQMs)
• Failure to meet these benchmarks can reduce reimbursement or trigger corrective action plans.

10). Provider-Specific Rules

CMS tailors requirements to the provider’s role.

• Pharmacists, physician assistants, and other non-physician practitioners may need proof of specialty certification or documented supervision
• Telemedicine professionals must hold a valid license in each state where patients are located and meet state-specific virtual-care rules

11). Additional Certifications CMS May Require

Depending on services offered, you might need extra credentials alongside standard Medicare enrollment.

12). Site Visits and Operational Standards

CMS may conduct on-site inspections during initial enrollment, revalidation, or whenever red flags arise. Inspectors confirm that:

• The office address on your application physically exists and matches signage
• Posted hours are accurate and staff are present
• Patient-care areas, record storage, and equipment meet health and safety rules
• Policies align with HIPAA, infection control standards, and local building codes

Passing the site visit proves that your practice is real, operational, and ready to serve Medicare and Medicaid beneficiaries.

CMS Telemedicine Credentialing Requirements

Telemedicine follows the same core CMS enrollment rules as in-person care, yet it adds a few extra layers that reflect the unique, screen-to-screen setting. Providers who plan to deliver virtual visits to Medicare or Medicaid patients must meet each standard below to secure reimbursement and avoid claim denials.

Here are the key CMS telemedicine credentialing requirements:

Provider Enrollment

• Complete the correct CMS-855 application and choose the telemedicine service type when prompted.
• Submit your National Provider Identifier (NPI), proof of active license, malpractice coverage, and any state-specific forms.
• Keep your information current in PECOS so payers can verify your status before processing remote-care claims.

Licensure Across State Lines

• Hold an active license in the state where the patient sits during the visit, even if you live elsewhere.
• Many providers rely on the Interstate Medical Licensure Compact or similar nursing and psychology compacts to speed up multi-state approval.
• Track renewal dates carefully; an expired out-of-state license can halt payment for every virtual visit.

HIPAA-Compliant Technology

• Use a HIPAA-compliant telemedicine platform for video, chat, and file sharing.
• Encrypt data in transit and at rest, maintain audit logs, and restrict user access to the minimum necessary.
• Provide patients with the standard Notice of Privacy Practices that explains how their data is stored and shared.

State and Federal Telemedicine Rules

• Follow your state’s practice standards, prescribing limits, and modality restrictions for virtual care.
• Some states enforce payment parity laws that require commercial plans to cover telehealth at the same rate as face-to-face visits; CMS often mirrors these rules for Medicaid.
• Document each visit just as thoroughly as an in-office encounter, including location of patient and provider.

Patient Consent

• Obtain informed telehealth consent before the first virtual session of the patient.
• Explain how the service works, any technology risks, and steps taken to secure data.
• Keep a signed or electronically acknowledged consent form on file, as CMS may request it during audits.

Supervision and Delegation

• If nurse practitioners, physician assistants, or other clinicians deliver remote care, meet CMS and state supervision or collaboration requirements.
• Clearly outline who can provide which services, how oversight is documented, and how escalation to a supervising physician occurs.

CMS Delegated Credentialing Requirements

Sometimes a health plan or large provider group lets a separate entity handle day-to-day credentialing. This is known as delegated credentialing and it comes with its own set of CMS rules. Even when the work is handed off, the original organization is still responsible for meeting every CMS standard.

Here are the key CMS delegated credentialing requirements:

Formal Delegation Agreement

A clear, written agreement must be in place before any work starts. The document should

• list every task the delegate will complete, such as primary-source verification or final credentialing decisions
• spell out performance targets and how results will be reported
• describe how the delegating organization will monitor, audit, and if needed, cancel the arrangement
• require the delegate to follow NCQA or an equivalent set of credentialing standards when the health plan is NCQA-accredited

Oversight and Accountability

The health plan—or other delegating group—keeps full responsibility for compliance. To show CMS that proper oversight exists, the plan must

• review and approve the delegate’s policies and procedures before work begins
• audit the delegate, usually once a year, to confirm rules are being followed
• maintain written records of every review, audit, and corrective action
• step in quickly if audits reveal non-compliance

Credentialing Standards to Maintain

The delegate has to apply all routine credentialing checks, including primary-source verification of

• active state license and any required specialty license
• DEA certificate if the provider prescribes controlled substances
• board certification when the specialty calls for it
• education, training, and recent work history
• current malpractice insurance with adequate limits
• sanctions, disciplinary actions, and the OIG exclusion list

These safeguards ensure every provider in the network is licensed, competent, and in good standing.

Revoking or Correcting Delegation

If audits show that credentialing standards are not met, the health plan must

• issue a corrective action plan with clear deadlines
• revoke the delegation if problems persist
• resume direct credentialing in-house or choose a new, compliant delegate

By keeping a close eye on every delegated activity, the health plan protects patients and stays aligned with all CMS credentialing regulations.

FAQs

What is CMS credentialing and why does it matter?

CMS credentialing is the process that confirms a provider’s identity, professional qualifications, and compliance record before allowing Medicare or Medicaid billing. Without it, claims will be rejected and you cannot treat covered patients.

Which core documents do I need to start a CMS application?

You will need an active state license, National Provider Identifier (NPI), malpractice insurance certificate, work history, education and training records, and a completed CMS-855 application (or the PECOS online equivalent).

How long does initial credentialing for CMS usually take?

Most clean applications pass through a Medicare Administrative Contractor in thirty to ninety days. Missing paperwork, pending license renewals, or background issues can extend the timeline.

How often must I complete CMS recredentialing or revalidation?

CMS requires recredentialing every three years for all enrolled providers. A separate revalidation notice can arrive sooner if you move, change ownership, or trigger other risk factors.

What is the difference between a CMS-855 paper form and PECOS?

CMS-855 is the paper enrollment packet. PECOS is the secure online portal that lets you fill out the same information electronically, upload documents, and track your application status. Use one method per enrollment cycle.

Can my practice delegate CMS credentialing to a Credentialing Verification Organization (CVO)?

Yes. A formal delegation agreement must spell out the CVO’s duties, performance standards, audit schedule, and termination clauses. Even with delegation, your organization remains accountable for meeting every CMS rule.

Does CMS perform site visits and why?

Yes. CMS or its contractor can conduct a site visit during initial enrollment, revalidation, or when they detect billing anomalies. Inspectors verify that the listed address exists, hours are posted, staff are present, and records are secure.

Do I need a separate state license for each location where patients are treated, including telehealth?

Yes. You must hold an active license in every state where the patient is located at the time of service. This applies to both in-person care and telemedicine appointments.

Imagine you’re running a healthcare practice, and a new physician joins your team. They’re experienced, talented, and eager to start helping patients.

However, there’s a hiccup—they haven’t been credentialed yet. Now, the clock’s ticking, and you’ve got patients to see.

What do you do? Do you hit pause until the credentialing process is complete, or is there a way to move forward?

It’s a scenario many healthcare providers face, and while it may seem like a sticky situation, it’s not all doom and gloom.

There are some ways to navigate these waters, and it’s essential to understand the dos and don’ts to keep things running smoothly.

Credentialing is a big deal. It’s how medical professionals get recognized and reimbursed by insurance companies like Medicare.

Essentially, the stamp of approval says, “Yes, this provider meets the necessary standards to offer services safely and effectively.”

Without it, patient safety and the integrity of the healthcare system could be at risk.

But here’s the kicker:

What happens if that new physician isn’t credentialed yet, and you need to see patients anyway?

It is a very critical situation, but the truth is, there are temporary solutions that can keep your practice moving forward.

Let’s see when and how a physician can see patients without being credentialed.

What Does It Mean to Be Credentialed?

Credentialing is the process where healthcare providers, like doctors, nurses, or specialists, are verified for their qualifications.

This process involves reviewing a provider’s education, training, licensing, malpractice history, and work experience to ensure they meet the standards of the healthcare institution and are eligible for insurance reimbursements.

While credentialing is typically a standard process for doctors, nurses, and other healthcare professionals, sometimes there is a delay between when a provider joins a new facility or health plan and when their credentialing is officially completed.

If a physician isn’t credentialed, they can’t officially bill insurance companies, including big players like Medicare.

Without that credentialing stamp of approval, they’re not recognized as a valid provider under those insurance contracts.

This can lead to a few complications:

First, you won’t be reimbursed for the services provided, and second, it could even raise concerns about compliance and patient safety, depending on the situation.

Without credentialing, health plans, including Medicare, Medicaid, or private insurers, don’t recognize a provider.

This means that:

• The provider cannot bill for services rendered.
• Patients might face out-of-pocket expenses if they choose to see a non-credentialed provider.
• Insurance companies won’t reimburse for services rendered by the non-credentialed provider.

Can Non-Credentialed Providers See Patients: Potential Risks

YES, in certain circumstances, non-credentialed providers can see patients—but it’s not as simple as just letting them dive in.

There are significant restrictions and potential risks involved that you need to consider before allowing any provider to treat patients without full credentialing.

Everything runs on high standards, strict protocols, and paperwork in healthcare.

Why?

Because patient well-being, legal obligations, and the financial health of a healthcare organization all depend on it.

Credentialing plays a considerable role in this system. It ensures that a provider meets specific qualifications and standards to safely treat patients and be authorized to bill insurance companies, including large payors like Medicare and private insurers.

But what happens when a provider isn’t credentialed yet and still sees patients?

Well, here’s where things get tricky.

Allowing a non-credentialed provider to see patients before completing the credentialing process can open the door to several risks that could harm your practice financially and legally.

Let’s take a closer look at these risks:

1). Reimbursement Denial

One of the most significant risks of seeing patients before completing the credentialing process is the potential for reimbursement denial.

Insurance companies, including major payers like Medicare and private insurance providers, have strict rules regarding credentialing.

They typically require that healthcare providers are officially credentialed and authorized before any services are eligible for reimbursement.

Insurers require that healthcare providers meet specific qualifications and have the necessary approvals before they are eligible for reimbursement.

Without proper credentialing, any services provided will likely be denied payment.

If a provider has seen patients without credentialing approval, they cannot collect payment for the services rendered until their application is processed.

This could lead to significant financial challenges for the practice, especially if the provider has seen many patients.

2). Out-of-Pocket Costs for Patients

Patients typically rely on their insurance coverage to help pay for medical services.

If a provider is not credentialed with the patient’s insurance, patients may be required to pay out-of-pocket for the services they receive.

This can create several problems for both the patient and the provider.

Insurance companies generally won’t reimburse for services rendered by non-credentialed providers.

As a result, patients will likely be responsible for the full cost of their care, which they may not have budgeted for.

Most patients expect their medical expenses to be covered by their insurance.

When faced with unexpected costs because their provider isn’t credentialed, it can lead to frustration, dissatisfaction, and even a loss of trust in the provider.

This can result in a negative impact on patient retention and the provider’s reputation.

3). Compliance and Liability Issues

Seeing patients without the necessary payer credentialing poses a significant legal risk, including compliance and liability issues.

Providers who fail to adhere to proper credentialing protocols may face legal challenges, especially if something goes wrong during care provision.

If a non-credentialed provider is involved in a malpractice case or any legal issue, they may find themselves without legal protection or coverage under their malpractice insurance.

This could leave the provider personally liable for the financial and legal consequences.

Healthcare organizations must comply with various regulations, including credentialing-related ones.

Providing services without completing the credentialing process could be seen as a violation of these regulations.

Failure to comply with credentialing requirements could sometimes lead to fines, sanctions, or even the termination of a provider’s license.

Physicians who see patients before their credentialing is complete take on considerable legal and financial risks. Malpractice claims, insurance issues, and violations of healthcare regulations could jeopardize their practice and professional standing.

When Can a Non-Credentialed Provider See Patients? Key Scenarios Explained

While proper credentialing is a cornerstone of healthcare compliance and reimbursement, there are specific circumstances where providers can legally see patients before their credentialing process is complete.

These exceptions provide necessary flexibility in the healthcare system while maintaining patient safety standards.

We’ve outlined the key scenarios below where providers may be permitted to practice prior to full credentialing approval:

Temporary Credentialing or “Provisional” Status

Sometimes, a provider may be granted temporary or provisional credentialing to see patients while the complete credentialing process is underway.

This is commonly seen when a physician joins a hospital or practice and needs to start seeing patients immediately, even if their full background check isn’t completed yet.

From an insurance perspective, provisional status can lead to service reimbursement, but it’s not guaranteed.

For example, Medicare might reimburse for the care a temporarily credentialed physician provides, but this arrangement is typically short-term and subject to various conditions.

Supervision by a Credentialed Provider

A non-credentialed provider may be able to see patients if they are working under the supervision of a credentialed provider.

This is common for non-physician providers, such as nurse practitioners (NPs) or physician assistants (PAs), who work under a supervising physician.

Let’s say a Nurse Practitioner is in the process of being credentialed by Medicare but has already started working at a primary care clinic.

While the nurse waits for her credentials, she may see patients if her supervising physician is present or available to oversee her care decisions.

When it comes to insurance, Medicare and other insurers typically reimburse the credentialed supervising provider for services rendered.

This means that while the supervising physician can bill for the care provided, the non-credentialed NP won’t be reimbursed directly.

The supervision arrangement ensures that the supervising physician remains legally responsible for the care provided and that billing is tied to the supervising physician’s credentials.

Emergency or Unforeseen Circumstances

There are situations in which emergency care or urgent needs arise, and a non-credentialed provider may be the only one available to treat patients.

In these cases, insurance companies like Medicare has specific emergency services and coverage guidelines.

For example, a doctor is not yet credentialed with Medicare but works in an urgent care facility.

One day, an unexpected influx of patients requires her to step in and see a patient with a complex condition.

While they are not credentialed, the facility calls her in due to the emergency, and she provides care.

For emergencies, Medicare and most other insurers will generally cover care provided by a non-credentialed provider.

This is because patient health and safety are prioritized in emergencies, and credentialing delays are recognized as an administrative issue.

Out-of-Network Providers

In some instances, a non-credentialed provider may not be in-network for an insurance plan, but patients may still be able to see them as out-of-network providers.

The patient would typically be responsible for a higher out-of-pocket cost, but the insurance may offer partial reimbursement.

For instance, a specialist who isn’t credentialed with a specific insurance company.

However, he agrees to see a patient who has that insurance.

The patient might still be able to get some reimbursement from their insurance provider, but it will likely be at a reduced rate, and they may need to pay higher co-pays or deductibles.

Medicare, for example, has a network of approved providers, but it does not allow patients to see out-of-network doctors.

However, if the provider is non-credentialed, reimbursement will likely be limited or unavailable, and patients might have to pay the full cost.

Telemedicine and Cross-State Licensing

With the rise of telemedicine, non-credentialed providers might also encounter questions related to cross-state licensing or telehealth provisions.

A physician who isn’t credentialed in a particular state may still offer services via telemedicine to patients in that state.

For example, a licensed physician in Texas hasn’t yet been credentialed by an insurance provider in Louisiana.

However, she offers telemedicine consultations to patients in Louisiana, raising the question of whether Medicare will reimburse those services.

Many insurance companies, including Medicare, are adapting to the rise of telemedicine.

Reimbursement policies are evolving, but if a provider is often licensed in the state where the patient is located, they may still be able to offer telehealth services, even if they are not yet credentialed with the insurance provider.

Do you want to help more patients and make your treatment better? Insurance paneling can help you a lot! More people can use your health care services when you join well-known insurance companies via insurance paneling.

Are you not sure what to do with the process of medical insurance paneling? Remember not to worry!
We’re here to help you all the way through.

Get to know the people who are giving out credentials i.e. the credentialing panel. It tells you what to do and what paperwork is needed to verify your skills. It will also help you meet the standards if you know the paneling rules for each insurance company.

Follow these simple steps to learn about insurance panels and help your practice grow. Let’s start!

Get paneled with any insurance company of your choice!

Schedule Free Consultation

Understanding Insurance Paneling In Healthcare

An insurance panel refers to the list of healthcare providers that a health insurance payer (e.g. insurance company) has contracted with to provide medical services to its members at pre-negotiated rates. Joining an insurance panel means that a healthcare provider, such as a therapist, psychologist, or counselor, has entered into an agreement with a health insurance company to become an in-network provider for that insurer.

As an in-network provider, the healthcare professional agrees to the insurer’s contracted rates for services rendered to the insurance company’s members. In return, the provider gains access to the insurer’s covered patient population, with the advantage that patients face lower out-of-pocket costs for services from in-network providers compared to out-of-network providers.

Important terms related to insurance panels include in-network providers, who are healthcare professionals that have joined an insurer’s panel, and out-of-network providers, who have not contracted with a particular insurance company. Health insurance payers create provider networks by credentialing and contracting with providers who meet their criteria.

In contrast, providers who remain out-of-network do not join insurance panels. Out-of-network providers can set their own rates and are not bound to the terms and conditions set by insurers. They provide services to patients covered by that insurance, but the patient must pay upfront and submit claims themselves to seek reimbursement from their insurer at the out-of-network rate. Here the provider does not get paid directly by the insurer.

Step-by-Step Process for Getting Paneled with Insurance Companies

When you get paneled with an insurance company, you agree to work with them as a provider for a certain health insurance plan. After this insurance paneling, patients with a certain health insurance plan can come to your practice for care, and you can bill their insurance company for it.

Do not forget! Remember! Insurance companies only prefer paneling those healthcare providers who can help them manage healthcare costs. They are always on the lookout for medical service providers who will take less money. In contrast, health care workers want to work with insurance companies that will pay them more for their services. So finding the perfect insurance company to get paneled with becomes challenging for a doctor, but not impossible.

Here is a step-by-step guide on how to get paneled with insurance companies as a healthcare provider:

Step 1: Getting Your Documents Ready

Before applying to get paneled with insurance companies, you will require a lot of information and documentation. It is crucial to arrange these documents to avoid any kind of delay and denial in your application approval.

The documents are:  

• Licensure information
• Practice address
• NPI number
• Resume
• Proof of malpractice insurance
• Taxonomy code (if you plan to bill Medicare/Medicaid)
• Proof of liability insurance from your landlord (if you rent)
• Advanced training or credentialing paperwork (if you have any)

Step 2: Searching For Different Insurance Companies

Now as you have arranged all these documents, it’s time to look for different insurance companies. Keep in mind that each insurance company has its own rules and payment rates. Even some of the companies require years of experience before they’ll sign insurance paneling agreements with you.

Therefore, before you look for an insurance company, here are some important things to keep in mind:

Network Size — Look for insurers with large coverage networks in your geographic area to gain access to more potential patients. Larger insurers like UnitedHealthcare, Aetna, and Blue Cross Blue Shield often have expansive networks.

Reimbursement Rates — You should compare the rates that different insurers offer for the typical procedures you do. Higher rates mean more revenue per patient visit. Get the fee plans from each insurance company to help you decide which one to go with.

Experience Requirements — Some insurers require 1-2 years of practice experience before they will accept you as a provider. Therefore, when choosing an insurance company, you should look at these requirements and pick one without strict experience requirements.

Credentialing Timeline — Keep in mind that provider insurance paneling process could take 3 to 6 months. Therefore, we advise you to pick plans like Cigna and Humana that can get you credentialed faster so you can start sooner.

Payment Reliability — Make sure that insurance companies pay claims on time. You can find out about this by reading online reviews and asking coworkers about their own experiences. This step is very important because it will help you make steady money, which is important for any healthcare business.

Plan Types — Determine which types of plans are dominant in your area – PPOs, HMOs, EPOs, etc. After that, focus on insurance companies that offer those specific plans to get in touch with more patients in your target area.

Value-Based Care Initiatives — Check with each insurance company to see what role they play in value-based care models, such as responsible care organizations (ACOs) or patient-centered medical homes (PCMHs). These programs can change how care is given and how much is paid for it.

Administrative Support — Last but not least, look for insurance companies that offer helpful tools like online portals, electronic claims filing, and specific reps for providers. This help could make it a lot easier for your team in the administrative process.

In addition, applying to 3-5 insurance companies that align with your geographic location, specialties, experience level, and business needs can position your practice for success as an in-network provider.

Step 3: Submitting The Credentialing Application

Health care workers must send a separate application to each health insurance company they wish to work with in order to begin the provider credentialing and paneling process.

Now, here’s a handy tip: many insurance companies use the Council for Affordable Quality Healthcare (CAQH) for provider insurance paneling. The streamlined application system created by CAQH is called CAQH ProView, and it really helps providers get their credentials more quickly.

Once you’ve sent your application via CAQH, the insurance company you’re targeting will provide you with a unique application number. This number is quite useful because it allows you to see where your application stands in the credentialing process and helps you keep track of everything.

The CAQH ProView application serves as a centralized repository for your professional and practice information. This means you won’t have to submit separate applications to multiple insurance companies, which is a real time-saver. This feature reduces administrative burden and ensures consistency in the information you provide to payers.

Now, it’s very important to get the entry form right. Make sure to include all the necessary documents, such as your professional license, certifications, malpractice insurance, and details about your business. Paying close attention to every detail when you apply will help speed up the process.

Step 4: Following Up After Application

Once you send your insurance paneling application to the health insurance company, you should check back soon. Most insurance companies will give you an idea of how long it will take to get your credentials, which is generally between 4 and 6 weeks. Check in with the provider relations group again in 4 weeks to see how your application is going.

Make sure you have your NPI number, Tax ID number, and application reference number with you when you follow up. Make sure they got your complete application. This includes everything that is attached, like licenses, certificates, liability insurance, and a DEA certificate. Make sure that no more information is needed to finish the process of getting credentialed as an in-network provider.

If the application is still being worked on, follow up again in 6 weeks. Always following up in a professional way lets them know that you want to be a part of their network.

If your application is turned down, request the reasons in writing. Not having enough malpractice insurance or not being eligible for Medicare are some common reasons for rejection. Fix any issues and try again.

In your subsequent application, mention improvements like extended hours, bilingual staff, EMR systems, or new services offered. Joining provider panels can take persistence through multiple application cycles.

You can finish the process quickly if you keep checking on your credentialing application. Checking status routinely demonstrates your commitment to the insurer’s network and patients.

Step 5: Reviewing The Terms of Approval

Once insurance companies agree to let you join their network of providers, it’s important to read the terms and conditions carefully before signing any contracts. This will help keep problems from happening in the future.

Key things to look over:

Reimbursement Rates — Look over the fee schedules for your specialty to make sure the rates of reimbursement are fair. Keep a close eye on the relative value units (RVUs) that go with the CPT codes you bill most often.

Billing and Coding — Make sure you can meet all the standards for billing and coding. You should know what variations, CPT codes, and ICD diagnostic codes are accepted. Also, look over how to submit claims, when they need to be sent, and whether electronic or paper claims should be used.

Authorization Requirements — Write down any permissions, referrals, or other paperwork that you need to get before you can perform certain medical services or procedures.

Contract Exclusions — Look out for exclusions for medical services, procedures, diagnoses, or types of providers that you might want to offer.

Appeals Process — Understand the process and timeframes for claim appeals and denials.

Penalties — Carefully review any fines, fees that need to be paid back, or other punishments for not following medical billing rules or other terms.

Provider Portal Access — Make sure you can get to the portals that let you check on things like a patient’s eligibility, the state of their claims, the authorization requirements, and more.

Checking the contract terms carefully before signing will help you avoid problems and make sure the process goes smoothly with the payer. Use the network contract checklist and also have a lawyer look it over.

Some Important Tips

Here are some important things to keep in mind that could make it easy for you to get on the insurance companies’ lists and keep you out of trouble.

Get Board Certification

Getting board certification is an important step you don’t want to skip if you want to be accepted by big health insurance companies. This license is very important because it shows that you’ve been trained and tested very carefully in your field. It’s all about showing that you meet the high standards of ethics and practice that insurers want to see.

Most big insurance companies need this license to make sure that the doctors in their network are providing good care. So, when you’re done with your residency, you can choose to take an exam in your field, whether it’s internal medicine, pediatrics, or something else. Passing that test shows that you know what you’re talking about and are dedicated to keeping updated in your field.

Certain smaller insurers might not need board qualification right away, but having it makes you much more competitive. It’s a great way to show that you are committed to giving excellent care that is based on convincing evidence. So, you should definitely think about it!

Consider Intern Policy

When working with insurance companies as a healthcare provider, it is important to carefully consider your intern policies. Unlicensed interns, even if they have finished their degrees, are often not credentialed to bill for services on their own. In some states, Medicare and Medicaid let billing happen under a supervisor. But in other situations, this might be considered insurance fraud. To prevent problems, look up the laws in your state and understand the insurance policies for interns from each insurance company. If you check the rules carefully at the start, you can feel sure about making internship opportunities that follow billing regulations.

Know The Required Time

When you apply to work with insurance companies, it is important to know how long they take to review and approve your application. Every carrier has its own rules about how long the vetting process will take. Check how long it usually takes to get things done. This will help you know what to expect. Knowing the needed time helps you check in at the right times. During the paneling process, there are often many requests back and forth. It is important to keep track of response times to avoid delays on your side. Following the insurer’s schedule shows your professionalism and dedication to building the partnership.

Remember Previous Disciplinary Action (if any)

When you apply to get paneled with insurance companies, it is very important to be honest about any past disciplinary actions against you. Having a record of discipline does not mean you will be disqualified. However, if you do not tell about it, it can hurt your trustworthiness and slow down the approval process. Insurance companies will check your background very carefully, so being honest is always the best choice. Explain what happened with the discipline and highlight the good actions you have taken since that time. Showing that you have grown and take responsibility can help reduce worries. If you are honest and clear, you can still be accepted even if you had a past issue.

Know If You Are A New Licensee

Some insurance payers like to choose providers who have many years of experience before bringing them on board. As a new licensee, find insurance companies that accept new practitioners. You might also think about starting with Medicaid or Medicare if your state permits new providers. Build up your patient roster and get that initial experience. In one or two years, you will be better able to meet stricter requirements from commercial insurers. Do your homework first. This way, you won’t waste time applying to panels that will not accept you.

Stay Informed

For healthcare workers, getting on the panels of insurance companies is a big deal, but it’s only the start. Learn the most recent rules and guidelines from these insurance groups. This is the most important thing you can do to keep a friendship going on with them.

Insurance firms are very active and often change their rules to keep costs low and help people get good care. Stay alert and watch for these changes. It will be simple to make your business fit what they want. Through trust and following through, this builds a strong connection that lasts. It also makes sure that you can keep your services running. Be ready to learn something new all the time. Read insurance company papers, go to their seminars, and communicate with the relevant people in your field every day.

Benefits Of Getting Paneled With Insurance Companies

Getting paneled with insurance companies brings many benefits to healthcare providers. The most notable of them is that it opens windows to new opportunities, and assists you to grow footfalls of patients to your practice.

It Gets You More Patients.

When you join a lot of different insurance networks, you can get more patients who can use their plans to find your healthcare office and get care services.

It Boosts Your Chances Of Making Money.

More people will be able to get medical care from you if you are on the panels of more insurance companies. With this, you may be able to potentially make more money.

It Makes It Easier For People To Get Multiple Care Services.

You can make it easier for people to get a variety of low-cost medical services. People who really need care but can’t pay for it will benefit from this.

It Improves Your Professional Image.

One way to boost your credibility as an insurance agent is to be in network with respectable firms. This proves that your schooling, experience, and license are at the very best level required by these insurance companies.

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Assisting with billing, credentialing and enrollment, BellMedEx has been consistently reliable from the first day of our relationship.

Dr. Mike

Internal Specialist Medicine

Top Features

✓ Provider Enrollment
✓ Provider Credentialing
✓ Provider Privileging

It increases enrollment turnaround times, decreases paperwork, and expedites timely reimbursement. The insurance company also takes less time to decide whether to take a provider on its panel or not.

This comprehensive guide will help you understand everything you need to know about delegated enrollment and credentialing.

What is Delegated Credentialing?

Delegated credentialing is an arrangement in which a healthcare entity gives its credentialing authority to another healthcare entity. For example, a preferred provider organization may legally ask a hospital to credential its providers.

The delegated healthcare entity becomes responsible for taking credentialing decisions on the delegating healthcare entity’s behalf. They can verify provider’s qualifications, state licensure, DEA registration, work history, and more.

A delegated healthcare entity is responsible for reviewing and analyzing provider’s qualifications and making credentialing decisions on behalf of delegating entities.

The delegated entity may require this data:

• Professional Liability Claims Settlement History
• CDS (Controlled Dangerous Substance) Certification
• Education Malpractice History
• DEA Registration
• Sanctions & Exclusions
• Disclosure Questions
• Board Certification
• State Licensure
• Work History
• Hospital
• Attestation

But remember that a delegating entity is ultimately responsible for compliance with regulatory bodies, federal, and state laws.

Who Can Delegate Credentialing and Be Delegated?

There are two major healthcare entities involved in delegated credentialing:

1. Delegated entity
2. Delegating entity

These healthcare organizations can be delegated:

• Provider Groups (single or multi-specialty or multi-location)
• Independent Physician Associations (IPA’s)
• Hospitals & Hospital Systems
• Specialty Provider Networks (Dental, Vision)

And these healthcare organizations can delegate:

• Provider Networks
• Independent Physician Associations (IPA’s)
• Preferred Provider Organizations (PPO)
• Health Plans (Cigna, Aetna, etc)
• Accountable Care Organizations (ACO’s)
• Specialty Provider Networks (Dental, Vision)

Fun Fact: Some entities like IPAs and SPNs can delegate and be delegated as well.

Not sure whether your healthcare organization can delegate or be delegated? Schedule a free consultation session now to learn everything you need before getting started with delegated credentialing.

Some Examples of Delegated Credentialing

Delegated credentialing is an arrangement where one healthcare organization lets another organization handle the credentialing process for them. It’s a way to streamline things by having a larger entity take care of the administrative work for smaller groups. Let’s look at a few examples to understand it better:

Example #1

Dr. Smith works at Community Hospital but also sees patients at the local clinic run by Metro Health Network. Instead of Dr. Smith having to go through credentialing twice, Metro Health allows Community Hospital to credential him on their behalf. This saves time and duplication of efforts.

Example #2

As another example, many health insurance plans don’t directly employ physicians. Instead, they contract with independent doctor groups and healthcare organizations to provide care for their members.

The insurance plan will delegate the credentialing of those outside doctors and groups to a third-party credentialing agency. That agency becomes responsible for ensuring all the doctors meet the insurance plan’s requirements before they can officially join the plan’s network.

This helps the insurance plan quickly build a network of high-quality doctors without investing in their own credentialing department.

What is a Delegated Provider in Credentialing?

A delegated provider in credentialing refers to the provider that was given the responsibility of credentialing another provider or organization. That is not usually the individual provider but a full-fledged healthcare organization.

What is an Authorized Agent?

Authorized agent is any entity elected by eligible healthcare entities to process delegated credentialing and query the NPDB (National Practitioner Data Bank) on their behalf. Remember the authorized agents may act for more than one entity.

What is a Delegated Entity in Healthcare?

Delegated entity in healthcare is the entity to which the administrative responsibilities were delegated by another healthcare entity (called the delegating entity). However, the delegating entity oversees the entire process to ensure accuracy and compliance.

A delegated credentialing entity is any party that enters into a delegated credentialing agreement with a delegating entity. It’s the entity that has been given the authority to credential the healthcare providers of a (delegating) credentialing entity.

What is a Delegated Credentialing Agreement?

A delegated credentialing agreement is a written document that outlines all the credentialing responsibilities to delegated and delegating entities. The agreement is important because some functions in credentialing remain in-house. But mostly, the entire credentialing process is delegated to an entity.

The agreement for delegated credentialing also details down the managed care standards, termination rights, required reporting, and more. For example, the required reporting section of the agreement shares things that need to be reported, including complaint monitoring, semiannual credentialing activity, and more.

Delegated vs Non Delegated Provider in Healthcare

The difference between delegated and non delegated providers in healthcare credentialing is the existence of delegated credentialing entities. Non-delegated providers are the ones whose credentialing is done by their associated healthcare facility. The process is called credentialing.

In non-delegated credentialing, the healthcare facility collects credentialing information from its associated providers for their credentialing. In delegated credentialing, the outside entity does this job in accordance with the written agreement.

Delegated Credentialing vs Credentialing by Proxy

Delegated credentialing transfers the credentialing authority from one entity to another, while credentialing by proxy (CBP) refers to the credentialing of telehealth or virtual healthcare practitioners.

CBP allows the prime source verification, meaning hospitals using virtual healthcare services can accept the credentialing work of the remote hospital. They don’t need to implement the full credentialing for providers who never visited or sit in the hospital.

Regulatory Bodies Involved in Delegated Credentialing

There are three major regulatory bodies and stakeholders that ensure quality, compliance, and patient safety in delegated credentialing.

1. NCQA (National Committee for Quality Assurance)

NCQA sets standards for healthcare quality and performance improvement. Their guidelines are considered crucial in ensuring that credentialing processes meet high standards of reliability and accuracy. Healthcare organizations align their practices with NCQA standards to increase credibility and quality assurance.

2. CMS (Centers for Medicare & Medicaid Services)

CMS oversees federal healthcare programs including Medicare, Medicaid, CHIP, and ACA-related initiatives. It also imposes regulatory requirements for healthcare entities involved in delegated credentialing, complying with federal laws, safeguarding patients, and ensuring billing integrity.

3. Local Government and Verification Processes

Healthcare entities and authorized agents may need to follow some rules set by local governments. For example, you need to verify credentials directly from primary sources such as medical schools, licensing boards, and previous employers. Meeting deadlines and following such guidelines are important in obtaining and maintaining delegated credentialing status at the local level.

Delegated Credentialing Requirements for Time

The NCQA and other regulatory agencies have many requirements and standards. And the most important ones are being strict on time frames for the primary source verifications (PSV) as listed below. 

This is just the PSV time requirement, look up the delegated credentialing agreement for a comprehensive list of requirements.

Delegated Credentialing Process (How Does Delegated Credentialing Work)

Your healthcare facility must abide by different requirements, especially set by NCQA, to participate in a delegated credentialing arrangement.

Delegating entities can also set their own standards for delegated credentialing.

Setting and following the process is important also because the regulatory bodies require certain elements for delegated credentialing, such as pre-delegated assessment, oversight audits, and more.

Here’s how to implement delegated credentialing:

1. Develop an Internal Credentialing Program

Make policies and procedures compliant with state, federal, and payer regulations. Establish a robust quality oversight program involving medical staff services, quality department, peer review committees, and other stakeholders. Allocate necessary resources including personnel, operational infrastructure, and credentialing software.

2. Complete Pre-Delegation Assessment

Conduct an initial audit to evaluate policies and procedures against NCQA, URAC, or CMS managed care standards. Review a sample of initial and re-credentialing files to ensure compliance with credentialing criteria. Assess staffing levels and performance capabilities to ensure all processes align with regulatory requirements.

3. Negotiate Delegated Agreement

Define and document the responsibilities of both parties (health plan or delegating entity and delegated entity) about credentialing activities. Agree on the frequency, content, and format of credentialing activity reports to be submitted to the health plan.

Clearly decide on how you will analyze performance and resolve non-compliance issues. Determine reimbursement rates and fee structures applicable under the delegated credentialing agreement.

4. Conduct Credentialing

Utilize a robust credentialing software to verify qualifications, licenses, certifications, and other credentials of healthcare providers. Maintain accurate and up-to-date provider rosters detailing status changes, new enrollments, and terminations. Submit provider rosters to health plans in the required format and within specified timelines.

5. Participate in Annual Oversight Audits

Prepare for annual oversight audits conducted by NCQA, CMS, or health plans to evaluate compliance with credentialing standards. Review policies, procedures, and credentialing files to ensure adherence to regulatory and accreditation requirements. And in case of any discrepancies, implement corrective action plans to maintain compliance and contractual obligations.

Pros and Cons of Delegated Credentialing

Delegated credentialing offers many benefits but also requires careful management of responsibilities, compliance, and oversight to ensure smooth operation.

Benefits of Delegated Credentialing

• Saves time and resources for health plans overwhelmed with new enrollments.
• Lowers costs compared to hiring internal credentialing staff.
• Reduces turnaround time, allowing quicker enrollment of providers.
• Leads to quicker reimbursements for delegating entities.
• Enables new providers to start quickly, improving patient care.

Downsides of Delegated Credentialing

• Health plans (delegating entities) may lose control over credentialing quality.
• Changes in payer requirements can cause confusion if not managed carefully.
• Delegating entities bear responsibility for credentialing decisions.
• Many health plans mandate NCQA accreditation for delegates.
• Routine NCQA audits add to administrative burdens.

Streamline Delegated Credentialing With BellMedEx

BellMedEx offers comprehensive delegated credentialing services and can act as an authorized agent to streamline all things credentialing and enrollment. We optimize the delegated credentialing process for healthcare organizations to ensure efficiency and accuracy, compliance, and administrative relief.

Get free consultation on how we can help you improve your revenue cycle and increase patient satisfaction with our leading delegated credentialing solutions.