Credentialing

Credentialing is the process of verifying a healthcare provider's qualifications — education, training, licensure, board certifications, malpractice history, hospital privileges — and enrolling them with insurance payers so they can bill for covered services. A provider without active credentialing cannot bill insurance, period. Every claim submitted under a non-credentialed provider's NPI generates an automatic denial. The credentialing process typically takes 60-120 days per payer, with major commercial payers (UnitedHealthcare, Aetna, Cigna, BCBS) often running longer due to backlog. Medicare credentialing through PECOS adds another 30-60 days. Medicaid credentialing varies dramatically by state. The CAQH ProView database is the universal data source most commercial payers pull from, but each payer also maintains their own internal enrollment system. Re-credentialing happens every 2-3 years per payer and requires updated CAQH attestation plus refreshed documentation. Credentialing failures cost real money: a single missed re-credentialing deadline can trigger weeks or months of denied claims under that provider's NPI before anyone notices. The most common failure modes are expired CAQH attestation, expired malpractice coverage on file, expired DEA registration, and lapsed state license — all preventable with a credentialing tracking system that monitors expiration dates across every payer relationship.