A Roadmap for New Practices: How to Get Credentialed and Ready for Business
Starting a new medical practice is exciting — but before you can open your doors and start seeing patients, there’s one mission-critical step you can’t afford to overlook: Provider Credentialing.
Credentialing is the process that verifies your qualifications, ensures compliance, and allows you to bill insurers. Done right, it sets the foundation for a thriving, profitable practice. Done wrong, it can mean months of lost revenue, compliance risks, and operational headaches.
🗂️ Table of Contents
Here’s your step-by-step roadmap, with extra detail and practical advice for first-time practice owners.
Step 1: Gather Your Documents
Credentialing begins long before you submit applications. The most common cause of delays is incomplete documentation.
Prepare these items in advance:
Identification – Government-issued photo ID, Social Security, and NPI number.
Education & Training – Diplomas, transcripts, internship, residency, and fellowship certificates.
Licensure & Certifications – Active state licenses, DEA registration, board certifications (with expiration dates tracked).
Employment History – An updated CV/resume covering your entire career with no unexplained gaps.
Insurance & Liability – Malpractice insurance policy, plus 5–10 years of claims history.
References – 2–3 professional peers who can attest to your qualifications.
✅ Upload all records into CAQH ProView early. Payers and hospitals pull directly from CAQH, which avoids duplicate paperwork.
Step 2: Apply for an NPI Number
Every provider must have a National Provider Identifier (NPI), which is used by CMS and insurers to track services and payments.
Apply via the National Plan and Provider Enumeration System (NPPES) portal.
Keep your NPI linked to your practice’s Tax ID and location. Incorrect data here can delay enrollment.
Without an NPI, you cannot bill Medicare, Medicaid, or private insurers.
Step 3: Submit Credentialing Applications
This is the most labor-intensive stage, often requiring careful tracking and persistence. You must submit applications to multiple organizations simultaneously, each with their own requirements, formats, and portals:
CAQH ProView – Required by most commercial payers; this centralized database allows you to upload documents once for multiple insurers.
PECOS – The Medicare Provider Enrollment, Chain, and Ownership System for Medicare enrollment.
Medicaid Portals – Each state has its own portal and requirements for Medicaid enrollment.
Commercial Payers – Blue Cross, UnitedHealthcare, Aetna, Cigna, Humana, and others each require applications.
Hospitals/Facilities – Applications for hospital admitting privileges and specific procedure privileging rights.
⏳ Timeline: Expect 90–120 days for approvals under ideal circumstances. Delays are common, as each payer has unique requirements and review schedules. Even a small oversight — such as an expired DEA certificate, a missing malpractice claims history, or inconsistent practice address — can set your application back weeks.
Track all submissions in a master spreadsheet or practice management system. Designate one owner (or outsource to an RCM partner like MBW RCM) to manage deadlines, follow up with payers regularly, and keep CAQH attestations updated every 120 days to prevent automatic denials.
Step 4: Primary Source Verification (PSV)
Credentialing staff must confirm all submitted details directly with the issuing institution.
Medical schools – Confirm diplomas, transcripts, and dates of graduation.
Residency & Fellowship Programs – Validate training completion and performance evaluations.
State Boards – Verify licenses, disciplinary actions, and any restrictions.
Board Certification Agencies – Ensure active certification status and expiration dates.
Insurance companies – Confirm malpractice coverage and liability limits.
Hospitals or prior employers – May be contacted to verify privileges and performance.
This process is called Primary Source Verification (PSV) and is required by both NCQA and The Joint Commission. It ensures that every credential, license, and certification you present is confirmed at the original source — preventing fraud and ensuring patient safety.
For further guidance, the National Association Medical Staff Services (NAMSS) has published its 2024 Ideal Credentialing Standards, which outline 13 core data elements and best practices for PSV, including telehealth and locum tenens providers (NAMSS Credentialing Standards).
⏳ Timeline: In 2025, NCQA tightened standards: PSV must now be completed within 120 days of approval (down from 180). Missing responses or delayed institutions can create bottlenecks, so proactive follow-up with schools, boards, and insurers is essential.
Keep a log of all institutions contacted and their response status. Many practices outsource PSV tracking to credentialing vendors or RCM partners to stay compliant with strict NCQA deadlines.
Step 5: Background Checks & Reviews
Beyond verification, payers run thorough compliance and risk checks to protect patients, networks, and facilities:
NPDB (National Practitioner Data Bank) – A national clearinghouse that flags malpractice claims, disciplinary actions, or sanctions across states.
OIG Exclusion List – Identifies providers barred from Medicare, Medicaid, or other federal programs; appearing here means automatic denial of participation.
Criminal Background Checks – May be state- or facility-specific, covering federal, state, and sometimes county records. Fingerprinting may be required.
Credit and Financial History – Some payers and hospitals assess financial responsibility to evaluate potential fraud risk.
Peer & Professional References – At least 2–3 colleagues must verify your clinical competence, ethics, teamwork, and overall professionalism.
In addition, facilities may conduct sanction checks against state disciplinary boards, DEA registration databases, and sex offender registries. These screenings ensure patient safety and safeguard payers against fraud.
Once completed, your file moves to a credentialing committee (hospital medical staff office, payer review board, or delegated credentialing organization). This committee reviews all findings, evaluates any red flags, and determines whether to approve, deny, or request further information.
Committees may:
Ask for clarifications on malpractice claims or gaps in work history.
Schedule interviews to discuss flagged issues.
Require corrective action plans or additional documents.
Depending on the payer or hospital, committee review can add 2–6 weeks to the process. Preparing clear, thorough files and addressing potential red flags in advance helps prevent delays.
Step 6: Enrollment & Contracts
Credentialing confirms your qualifications, but enrollment activates payment and opens the door to reimbursement.
You are officially added to payer networks, meaning patients can see you in-network.
Contracts, participation agreements, and fee schedules are signed; these outline reimbursement rates and obligations.
Your NPI and Tax ID are linked in payer systems for billing, allowing claims to be processed.
Enrollment is handled through systems such as PECOS (Medicare), Medicaid portals, and commercial payer contract departments.
Some payers require additional steps like EFT (electronic funds transfer) setup, W-9 submission, or EDI enrollment for electronic claims.
⏳ Timeline: Enrollment can take several additional weeks beyond credentialing, as contracts must be reviewed, negotiated, and countersigned. Medicare PECOS approval often takes 60–90 days; commercial payers vary. Find out The Difference Between Provider Credentialing and Enrollment.
Credentialing ≠ Enrollment. Credentialing verifies qualifications; enrollment establishes contracts and billing access. Both are required before you can submit claims and receive reimbursement.
Step 7: Re-Credentialing & Ongoing Monitoring
Credentialing is not a one-and-done process. It requires continuous oversight to maintain compliance and protect your revenue cycle.
Commercial Payers: Require re-credentialing every 2–3 years, with full file review and updated attestations.
Medicare: Requires revalidation every 5 years through PECOS, including ownership and practice location checks.
NCQA (2025 updates): Monthly license monitoring is now mandatory, alongside continuous monitoring of sanctions, disciplinary actions, and malpractice claims. Many payers are adopting real-time alerts to flag compliance risks.
Ongoing Monitoring: Practices should implement systems or outsource to RCM partners for ongoing checks of DEA status, board certification expirations, and malpractice coverage renewals.
Failure to re-credential or maintain active monitoring can cause claim denials, termination from payer networks, compliance violations, and even reputational harm. Staying proactive prevents disruptions and keeps your practice in good standing.
Common Pitfalls to Avoid
Starting too late: The 90–120 day window can easily stretch longer. Begin well before your practice opens; some payers can take 150+ days.
Incomplete or inconsistent files: Even one outdated CV, mismatched address, or missing signature can reset your timeline. Always cross-check information across CAQH, PECOS, and payer applications.
Mixing up terms: Credentialing verifies qualifications, licensure, and training. Enrollment establishes billing ability, contract terms, and reimbursement rights. You need both, in sequence.
Poor tracking & reminders: Licenses, DEA numbers, malpractice coverage, and board certifications must never lapse. Use calendar reminders or software to track renewals.
Ignoring follow-up: Not checking application status or assuming payers will notify you causes delays. Call or email regularly to confirm progress.
No dedicated point person: Without someone owning the process, tasks slip. Assign staff or partner with an RCM vendor to manage timelines and updates.
Also read what are the Top Reasons Why Credentialing Is Crucial for Medical Practices here.
How MBW RCM Can Help
At MBW Revenue Cycle Management, we guide new practices through the complex world of credentialing and enrollment — so you don’t lose time or money.
We manage CAQH, PECOS, Medicare, Medicaid, and commercial payer enrollment.
We oversee initial credentialing, re-credentialing, and continuous monitoring.
We use automation and expert oversight to cut delays and prevent costly errors.
We safeguard your practice from denials, lost revenue, and compliance risks.
Ready to launch your practice without credentialing delays? Partner with MBW RCM today — let us handle the paperwork so you can focus on patient care and growth.
