Credentialing & Provider Enrollment FAQs
Understanding Credentialing and Enrollment
What is medical credentialing and why is it required?
Medical credentialing is the process of verifying a provider’s qualifications, licenses, education, and training so insurance payors can confirm that a provider meets their participation standards. It’s required before a provider can bill and receive reimbursement from insurance companies.
What’s the difference between credentialing and provider enrollment?
Credentialing verifies a provider’s credentials, while enrollment connects that provider to an insurance payor’s network so claims can be submitted and paid. Both steps are needed for a provider to start billing.
What is payor credentialing?
Payor credentialing refers to the process of becoming approved by insurance companies or managed care organizations so you can provide covered services to their members.
Who needs to be credentialed?
Any licensed healthcare professional who wants to accept insurance, including physicians, therapists, and allied health providers, needs to be credentialed with each payor they intend to bill.
Credentialing with Insurance Companies
How long does credentialing take?
Most credentialing processes take 60 to 120 days. Timeframes depend on the payor, specialty, and whether all required documents are submitted accurately.
Can I see patients before I’m credentialed?
You can see patients, but you generally cannot bill insurance until credentialing is complete. Some payors allow retroactive billing once approval is finalized, but many do not.
What documents are needed for credentialing?
Common items include your professional license, DEA registration, malpractice insurance, W-9, CAQH profile, resume or CV, and NPI numbers.
Do I need both individual and group enrollments?
Yes. Each group needs a Type 2 NPI and a contract with the payor. Each provider must then enroll individually under that group.
Working with a Credentialing Company
What does a credentialing services company do?
A credentialing company manages the entire process — collecting documents, preparing applications, submitting to payors, and tracking progress — so providers can focus on patient care.
How much do credentialing services cost?
Pricing varies depending on the number of providers, payors, and the scope of work. Most practices find outsourcing credentialing saves time and reduces costly delays.
Why outsource credentialing instead of doing it in-house?
Professional credentialing teams have established contacts, standardized workflows, and tools that streamline approvals. This shortens timelines and prevents rejections caused by missing or outdated data.
How does pie handle credentialing differently?
pie combines technology and experience to manage credentialing efficiently. Clients receive regular updates, full visibility into application status, and proactive follow-up with each payor.
The Credentialing Process
What are the steps in the credentialing process?
Typical steps include data collection, CAQH attestation, application submission, payor review, and final contracting. Each step must be completed accurately for approval.
What causes delays in credentialing?
Incomplete documentation, outdated CAQH profiles, or errors on applications can extend processing time. Having all information verified and up to date prevents most delays.
What happens after credentialing is complete?
Once approved, providers receive effective dates and may begin billing. Some payors require separate contracting or EFT setup before payments can be issued.
How often do providers need to recredential?
Most payors require recredentialing every two to three years. Maintaining current licensure, malpractice coverage, and CAQH attestations ensures continuous participation.
Maintenance and Updates
What is recredentialing or revalidation?
Recredentialing is the periodic review of your qualifications by each payor to maintain network participation.
How do I update my CAQH profile?
Log into CAQH ProView, make any necessary edits, and re-attest to confirm accuracy. Many payors pull directly from CAQH, so updates there are critical.
What if my business information changes?
Any change in name, address, ownership, or tax ID must be reported to each payor. Failure to update this information can interrupt claims processing.
Does pie provide ongoing credentialing maintenance?
Yes. pie offers maintenance plans that include recredentialing, CAQH management, and tracking expirables like licenses and malpractice certificates.
Specialty and Scenario-Based Questions
How does credentialing work for telehealth providers?
Telehealth credentialing follows the same process, but payors often require confirmation that services are delivered from an approved location and within the provider’s licensed states.
Do group practices need a Type 2 NPI?
Yes. A Type 2 NPI identifies the group or organization for billing. Each individual provider also needs a Type 1 NPI.
Can one credentialing application cover multiple locations?
Sometimes. Some payors credential by group or tax ID, while others require separate applications for each location.
What’s different about Medicaid and Medicare credentialing?
Medicaid and Medicare have their own enrollment systems and rules. Many states require separate applications for each Medicaid managed care organization.
Getting Started with pie
How do I get started with pie’s credentialing services?
Schedule a consultation, and our team will review your goals, practice structure, and target payors to recommend the best approach.
What happens after I schedule a consultation?
You’ll receive a confirmation email with meeting details and a link to provide basic practice information. This helps us prepare your customized credentialing plan.
How will I know when my enrollments are complete?
pie provides bi-weekly updates showing submission dates, payor status, and next actions. You’ll always know exactly where your applications stand.