Insurance Credentialing - The Foundation of Your Healthcare Business

Credentialing is the process of contracting with insurance carriers/payers to become a participating and preferred provider within their respective network. Without proper credentialing in place, a practice will be unable to provide care for patients covered by a particular insurance company.  Patients specifically seek out healthcare providers that are contracted by their insurance carrier so they can get the higher level of benefit when obtaining healthcare services.

 Typically, the provider's experience, qualifications,  and medical practices are validated as part of the credentialing process.  Credentialing with insurance carriers can be a long and tedious process. This article gives you some insight so you can avoid some of the pitfalls that can cost you big dollars if not handled correctly.  Consider being properly credentialed the foundation of your business.

Typical items that you will need before you begin your credentialing process:

  • Credentialing packets/application forms from your selected top insurance carriers (hard copy or web links to online packets)
  • Articles of Corporation
  • W-9 and or IRS Form CP 575 (IRS generated letter after you receive your Tax I.D.)
  • Certificate of Insurance (Professional Liability/Malpractice Insurance)
  • Type I NPI (Individual National Provider Identifier)
  • Type II NPI (Organizational National Provider Identifier)
  • State Medical License
  • Federal DEA License
  • CDS (Controlled Dangerous Substance) License
  • Occupational License
  • Drivers License
    • CLIA  (Clinical Laboratory Improvement Ammendement) Certificate  (click here to go to site)
  • Medical Diplomas
  • Board Certifications
  • CME (Continuing Medical Education)  Certificates for the past 2 years
  • Taxonomy Code (for your specialty)


  • Curriculum Vitae (month/year format)
  • Names/addresses/telephone numbers of professional colleagues
  • Business bank account information with account representative contact
  • Hospital affiliations

**Note***Keep up-to-date copies of licenses and certificates in a folder entitled, "Credentialing Documents". Providers should always maintain original certificates and licenses in a secure file in their office, and only share legible copies with qualified staff or vendors as needed.  User IDs and passwords should also be safeguarded. 

For your geographical location, seek out the top ten to fifteen insurance payers that you will likely file claims to for reimbursement.  If you don't know where to begin, the billing office at your local hospital may provide you with a listing.  

Call the insurance carrier/payer and ask for Provider Relations.  The representative will assist you with all of the necessary forms to enroll with their plans.  Keep in mind that payers such as Blue Cross Blue Shield have multiple plans, and you may wish to enroll in both PPO and HMO, etc.  If you don't know what type of plans that are offered by a payer, ask up front.  Also, ask if the carrier participates in CAQH.

Council for Affordable Quality Healthcare or CAQH

Many health plans...one solution.  Under the CAQH program, providers use a standardized application and a common database to submit one application to one source to meet the needs of all of the health plans and hospitals participating in the CAQH program. To maintain the accuracy of the provider's data, CAQH sends out a reminder every 90 days for providers to re-attest to their information. This is an extreme time-saver for healthcare providers.  Just keep your CAQH account up-to-date and allow insurance carriers to retrieve it.  If a carrier doesn't participate in the CAQH program, just copy/paste from your CAQH application into another application.  It really makes credentialing less of a hassle by maintaining a CAQH account.  Web link: http://caqh.org/


Most experienced credentialing specialists start with Medicare and Medicaid plans.  One of the most efficient is the PECOS (Provider Enrollment, Chain and Ownership System) online enrollment for Medicare.  If you have all of the necessary information at your fingertips, it doesn't take long at all.  PECOS will allow you to perform an audit on your application before you complete it to ensure that all required fields are completed.  This avoids your application being returned to complete that one little piece of information which can cause costly delays. PECOS web link: https://pecos.cms.hhs.gov/pecos/login.do


Contact your state's Medicaid program to find out contracting requirements. Many states offer multiple healthcare plans, you will want to be aware of all of them. Also, keep in mind to seek out forms to ensure that you participate in Medicare Cross-over.

NPI Registry or NPPES (National Plan & Provider Enumeration system):

Type 1 – Health care providers who are individuals, including physicians, psychiatrists and all sole proprietors. An individual is eligible for only one NPI.

Type 2 – Health care providers that are organizations, including physician groups, hospitals, nursing homes, and the corporations formed when an individual incorporates him/herself.

If you are an individual who is a health care provider and is incorporated, you need to obtain an NPI for yourself (Type 1) and an NPI for your corporation (Type 2).

Health care providers who are individuals are eligible for an Entity Type 1 (Individual) NPI. If these individuals incorporate themselves (i.e., if they form corporations) and the corporations are health care providers, the corporations are organization providers that are eligible for an Entity Type 2 (Organization) NPI.

If either of these health care providers (the individual or the corporation) are covered providers (i.e., providers that send electronic transactions) under HIPAA, the NPI Final Rule requires them to obtain NPIs. Visit the CMS website for more information:  http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/index.html?redirect=/NationalProvIdentStand/02_WhatsNew.asp

Keep your NPI Registry up-to-date.  Providers are required to update any changes that may affect their accounts within 30 days of the change. 

Web link: https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do 

Keep your insurance carrier contracts up-to-date and make sure that you submit pertinent changes that may affect your contracting (i.e. adding another location to your practice, adding/removing providers for your group).  Some providers do not realize that they may need to re-credential with carriers if moving from one medical group to another.  Most of the time, that is the case.  You may be asked to re-credential or re-attest with carrier(s) every two years.

Credentialing  doesn't have to be an aggravating task.  The key is to keep your credentialing documents organized, updated, and where you can put your hands on them when you need them.  Stay on top of outstanding applications, and document the process along the way recording the person that was spoken to, date and time of the conversation, and important details of the conversation.  Maintain a file for each carrier/payer so that you can quickly reference applications and contracts.   Be prepared for a time-line of 90-120 days for your application to be approved.  If a provider delegates this very important task to another party, have regular meetings to get status of  the process.