Credentialing a new provider: a 120-day timeline

The most common credentialing mistake is starting too late. A new provider can be hired, licensed and ready to see patients, but if their payer enrollments aren’t effective, their claims will be denied with codes like CO-B7: provider not eligible on this date of service.

Commercial payers often take 90 days or more to approve an application. Starting 120 days before the provider’s first patient visit gives you enough room for the slow ones.

Day 120: collect documents

Gather everything once, in one place:

• State medical license and DEA registration
• Board certification and education history
• Malpractice insurance certificate and claims history
• Curriculum vitae with month-and-year dates and explanations for any gaps
• National Provider Identifier (NPI). If the provider doesn’t have one, apply through NPPES now; it is usually issued quickly.

Day 110: CAQH ProView

Most commercial payers pull credentialing data from the provider’s CAQH ProView profile. Complete it fully, upload current documents, authorize the payers you work with to view it, and attest.

Profiles must be re-attested every 120 days. A lapsed attestation stops credentialing with every payer that relies on it.

Day 100: Medicare and Medicaid

• Medicare: enroll the provider through PECOS and reassign their benefits to your group. In most cases Medicare allows billing for services up to 30 days before the application was filed, but don’t rely on that window.
• Medicaid: each state runs its own enrollment. Some require the provider to be enrolled before Medicaid managed care plans will credential them.

Day 90: commercial payers

Submit applications to each commercial plan you contract with. For each one, confirm whether the provider is being added to your existing group contract or needs a new agreement.

Unlike Medicare, most commercial plans don’t pay retroactively for visits before the effective date.

Days 90 to 0: follow up on a fixed schedule

Applications stall without follow-up. Check each one every two weeks, log the reference number and the name of the person you spoke to, and answer requests for information the same day.

If the provider needs hospital privileges, run that application in parallel. Hospital credentialing committees often meet only monthly.

Day 0: confirm before scheduling

Before booking patients, have an effective date in writing for each payer. Where enrollment is still pending, schedule patients with that payer for after the expected date, or agree with the provider how those visits will be handled.

After go-live

Credentialing doesn’t end at approval. Track CAQH re-attestations, license and DEA renewals, Medicare revalidation (generally every five years) and commercial recredentialing (often every three years).

Our credentialing team keeps every one of these dates on a tracker your practice can see, and follows up with payers until each application is approved.