The Credentialing Steps Explained

1) Initial Evaluation

This step decides if credentialing will succeed before anyone touches a form.

Goal: Confirm readiness, risk, and requirements.

What you evaluate:

• Provider type (MD/DO/NP/PA, specialty)

• Practice structure (solo, group, multi-location)

• State license status and expiration

• Board status (certified, eligible, or in progress)

• Hospital privileges requirements (if needed)

• Malpractice coverage status

• Any gaps in work history or training

Output: A credentialing plan:

• Target payers

• Submission sequence

• Expected timelines

• Missing items list

2) Documents Handling

Credentialing is document-driven. Payers won’t “assume.” They verify.

Goal: Build a complete credentialing packet that matches payer rules.

Core document checklist:

• NPI confirmation (Type 1 and Type 2 if applicable)

• State license(s)

• DEA certificate (if prescribing controlled substances)

• Board certification proof (or eligibility letter)

• Malpractice COI (Certificate of Insurance)

• CV with month/year format and no gaps

• Driver’s license or passport

• W-9 (correct tax name and TIN)

• Practice address verification

• Liability insurance details

• Hospital privileges letter (when required)

3) Data Maintenance

Credentialing fails when data conflicts across systems.

Goal: Keep provider data consistent everywhere.

You maintain:

• Legal name formatting (exact match)

• Practice addresses (suite numbers matter)

• Phone/fax consistency

• Taxonomy codes

• Specialty and subspecialty labels

• Group affiliations

• EFT/ERA details for payments

• Ownership and managing control info

4) CAQH Attestation / Re-Attestation

CAQH is where many payers pull your profile. It’s not optional in most markets.

Goal: Complete the CAQH profile and keep it re-attested on time.

Key actions:

• Populate every section fully

• Upload current documents

• Ensure work history has no unexplained gaps

• Add practice locations and billing details correctly

• Attest the profile (and re-attest when due)

5) PECOS Management / Revalidations

PECOS matters for Medicare enrollment and compliance.

Goal: Maintain CMS enrollment data and prevent billing privilege issues.

What you manage:

• Correct entity enrollment (individual vs group)

• Reassignments to the group

• Authorized officials and delegated officials

• Practice location updates

• Revalidation notifications and deadlines

6) Application Submission to Payer

Now you submit payer-specific applications. Every payer has quirks.

Goal: Submit complete, accurate applications with all attachments.

Typical submission routes:

• Payer portals

• CAQH-linked submission

• PDF application packets

• Clearinghouse or third-party systems

What “complete” means:

• Application signed and dated correctly

• Supporting docs attached

• W-9 matches the tax entity

• EFT forms correct

• Group details aligned

7) Tracking

Submitting isn’t progress unless you can prove it.

Goal: Track each payer, each provider, each status—daily.

Track fields that actually matter:

• Payer name

• Provider name/NPI

• Submission date

• Portal confirmation number

• Assigned rep name

• Current status

• Missing items requested

• Last contact date

• Next follow-up date

• Expected effective date

• Approval date

• Contract status

Credentialing without tracking becomes guesswork. Guesswork becomes lost revenue.

8) Follow Up

Follow-up drives completion. Silence creates delays.

Goal: Move applications through payer queues.

Follow-up rhythm:

• 7–10 days after submission

• Weekly during review

• 48 hours after a request for information

• Escalate after 2–3 stalled cycles

What you ask in follow-up:

• “Is the application complete?”

• “Any outstanding verifications?”

• “Any missing documents?”

• “What is the expected credentialing committee date?”

• “Can you confirm the effective date policy?”

9) Reporting

Reporting turns credentialing from “busy work” into performance.

Goal: Make credentialing measurable.

High-impact KPI reporting:

• Average days to credential by payer

• Denial rate and reasons

• Pending count by stage

• Provider go-live forecasting

• Revalidation calendar health

• Contract turnaround time

Reports help leadership decide:

• Which payers are worth it

• Where bottlenecks live

• How to forecast revenue start dates

10) Payer Contract Evaluation & Negotiation

Credentialing gets you in. Contract terms decide your profit.

Goal: Secure better reimbursement and cleaner terms.

What you review:

• Fee schedule (by CPT and specialty)

• Timely filing limits

• Prior authorization burdens

• Claims appeal timelines

• Recoupment clauses

• Credentialing and termination terms

• EFT/ERA obligations

• Patient steerage requirements

Negotiation levers:

• Market demand for your specialty

• Multi-location growth

• Patient volume projections

• Quality metrics and outcomes

• Competing payer offers

11) Management of All Credentials

This step prevents future disasters.

Goal: Maintain every credential and renewal in one controlled system.

You manage:

• License renewals

• DEA renewals

• Board certification renewal timelines

• CME documentation (as required)

• Malpractice renewals

• BLS/ACLS (for certain settings)

• Hospital privileges updates

• Sanctions monitoring (OIG/SAM, payer checks)

12) Credentialing Update

Credentialing changes constantly. Updates keep payers aligned.

Goal: Notify payers and update profiles when anything changes.

Changes that require updates:

• New address or suite

• New phone/fax

• Legal name change

• Tax ID change

• Ownership changes

• New specialty or taxonomy

• Provider leaving or joining a group

• New hours or location status

FAQ: Physician Credentialing Process

Is credentialing the same as payer enrollment?

They overlap, but credentialing is verification and approval. Enrollment activates billing under the payer.

Do I need CAQH for every payer?

Many commercial payers require it or use it heavily. It reduces repetitive paperwork.

What is PECOS used for?

PECOS supports Medicare enrollment and ongoing CMS updates and revalidation management.

What’s the biggest cause of delays?

Incomplete packets and conflicting data across CAQH, PECOS, and payer applications.