Insurance credentialing checklist for new providers and practices

Before a provider can be paid by an insurance plan, they need to be credentialed and enrolled with that plan. The process can take several months, and a single missing document can send an application to the back of the line. The best way to avoid delays is to have everything ready before you start.

Documents and details to gather

• NPI numbers: an individual (Type 1) NPI for each provider, and an organizational (Type 2) NPI for the group practice if applicable.
• State license for each state where the provider practices, plus a DEA registration if they prescribe controlled substances.
• Board certification and education and training history, including dates.
• Malpractice insurance certificate of coverage, with current limits and dates.
• Work history, with explanations for any gaps.
• Practice information: tax ID and W-9, legal business name, service addresses, phone and fax, and office hours.
• Hospital affiliations or admitting arrangements, if applicable.

Set up CAQH ProView

Most commercial payers pull provider information from CAQH ProView. Complete the profile, upload current documents, authorize the payers you’re applying to, and re-attest every 120 days so your information stays active.

Enroll with government payers

Medicare enrollment is completed through PECOS, and Medicaid enrollment goes through your state’s program. Each has its own forms and timelines, so start early.

Apply to commercial plans

Decide which plans matter most for your patient base, confirm whether each panel is open, and submit applications. Track every application with dates, reference numbers and follow-up notes.

Don’t forget after approval

• Confirm your effective date before billing under a new plan.
• Link each provider to the group so claims pay correctly.
• Calendar expiration dates for licenses, malpractice coverage and re-credentialing.