Get credentialed: NPI, CAQH, PECOS, payer contracting

Goal: enrolled and contracted with every payer you’ll bill, before you need the revenue. The planning fact: commercial credentialing takes 90 to 180 days per payer, mostly in parallel, with the slowest payer setting your start date. Nothing in your launch has a longer lead time. Start the moment you have an entity, address, and identifiers.

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Four layers people confuse

A payer can credential you without contracting you, and contract you while still misconfigured. Track all four per payer.

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Step 1: Identifiers (once)

Type 1 NPI per clinician, Type 2 NPI for the entity, both via NPPES. Create a CMS Identity & Access (I&A) account (registration): one login for NPPES and PECOS. Registration requires the clinician’s SSN, so they create their own account and delegate staff access through I&A. Never share credentials.

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Step 2: CAQH ProView (once, then maintain)

Most commercial payers pull credentialing data from CAQH. Complete every field, upload every document, and authorize each payer. Then maintain: re-attestation is quarterly, and an expired attestation silently stalls everything in flight. Recurring calendar entry, named owner.

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Step 3: Medicare and Medicaid

Medicare via PECOS: the practice enrolls (855B), clinicians reassign benefits (855R), and CMS-588 designates the bank account. Medicaid is state by state, each its own portal and timeline. Medicare allows limited retroactive billing; commercial payers mostly don’t, so commercial starts first.

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Step 4: Commercial payers

Per payer: request participation, point them at CAQH, answer every information request same week (their clock pauses, yours doesn’t). When the contract arrives, read the fee schedule before signing. Know your top 20 codes’ rates vs. Medicare. Log the effective date and timely filing limit.

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Step 5: Convert enrollment into money

Contracting done is not money flowing. Complete EFT/ERA enrollment per payer (directory), then run a test claim through the full cycle and watch it deposit and reconcile.

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Maintenance (assign an owner)

Re-credentialing every 2 to 3 years per payer. CAQH quarterly. License, DEA, and malpractice renewals feeding CAQH. Any change (address, entity, bank, new clinician) propagated to every payer. Each new hire restarts this page, 90 to 180 days before you need them billing. Credentialing services charge per clinician and are usually worth it for groups.