Imagine you’re a new specialist joining a group practice or a solo physician opening your clinic. You begin seeing patients, only to have your claims rejected by insurance companies. The reason? You haven’t completed the necessary steps on how to get credentialed with insurance companies, a process essential for getting reimbursed for the services you provide

Credentialing is essentially the insurance companies’ way of doing homework on you. They need to verify that you are who you say you are—that your medical license is valid, that you’ve completed your training, that you have no major red flags, and that you’re qualified to provide the care you’re billing for. If you don’t complete this process, insurers won’t pay you—even if your treatment is flawless. 

Whether you’re a physician, a therapist, or a hospital CEO, credentialing is your golden ticket to being reimbursed for in-network services. 

Why Credentialing Matters for Your Practice or Hospital 

Credentialing isn’t just a formality—it’s directly tied to your bottom line. Being in-network with insurance companies means more patients will come through your doors. Most people don’t want to see an out-of-network provider because of the cost, so your ability to join insurance panels expands your reach and revenue. 

More importantly, good credentialing sets the stage for strong revenue cycle management (RCM). Your claims will be denied or delayed if you’re not appropriately credentialed. You’ll waste time appealing rejections or chasing payments. That translates into cash flow problems, strained operations, and frustrated staff. 

For example, a cardiology group that fails to update a provider’s CAQH profile might suddenly see a spike in claim denials from UnitedHealthcare. It’s a minor administrative mistake, but it could cost them tens of thousands in delayed payments. 

In short, credentialing matters because providers:  

• Get Paid Faster: Insurance companies won’t reimburse non-credentialed providers. 
• Enhance Patient Volume: Patients prefer in-network providers due to lower out-of-pocket costs. 
• RCM Efficiency: Streamlined credentialing reduces denials and delays. 
• Compliance: It’s a regulatory requirement and mitigates legal risks. 

Common Credentialing Pitfalls (and How to Avoid Them)

Even experienced providers and hospitals stumble here. For example, one of our clients—a growing multi-specialty group—missed a re-credentialing deadline with Blue Cross, causing a temporary suspension and $85,000 in delayed payments.

Credentialing is not just data collection. It’s process management, regulatory compliance, and contract negotiation. Small mistakes have significant consequences, from failing to update CAQH to submitting incomplete work histories. This is why many practices outsource credentialing to experts who manage it full-time.

Who Needs to Be Credentialed? 

It’s not just doctors. Anyone providing care and billing insurance should be credentialed. That includes: 

• Solo MDs or DOs
• Nurse Practitioners (NPs) and Physician Assistants (PAs)
• Mental Health Therapists and Counselors
• Specialists (Dermatologists, Gastroenterologists, Orthopedic Surgeons)
• Group Practices
• Hospitals and Surgical Centers
• Allied Health Professionals

Let’s say a hospital hires a new OB-GYN. That provider must be credentialed individually, even if the hospital is already contracted with the insurer. Large systems often fall short here, assuming one credential applies to everyone. It doesn’t. 

Step-by-Step Process to Get Credentialed with Insurance Companies

Let’s move towards the step-by-step process of getting credentialed with insurance companies. 

Step 1: Get Organized Before You Start 

Credentialing is a paperwork-heavy process. Before you apply, gather all your key documents. Trust me—it’s much less painful if you’re organized from the beginning. 

Here’s what you’ll typically need: 

• Your state medical license(s) 
• DEA certificate (especially if you prescribe controlled substances) 
• Board certifications (if applicable) 
• Proof of malpractice insurance (often a “face sheet”) 
• Education history (med school, residency, fellowships) 
• Work history going back at least 5–10 years 
• National Provider Identifier (NPI) number 
• A completed W-9 (tax form) 
• Hospital privileges (if applicable) 
• A CLIA certificate if you run labs in-house 

Step 2: Create or Update Your CAQH Profile 

CAQH ProView is often described as the “LinkedIn of medical credentialing”—a centralized portal where providers maintain updated credentialing information that insurance companies can access and verify.

• Register at https://proview.caqh.org 
• Complete your profile thoroughly and accurately. 
• Upload supporting documents. 
• Re-attest your profile every 120 days or when notified. 

For example, an internist changes her DEA address and forgets to update CAQH. Aetna tries to verify her information but finds a mismatch, causing her credentialing process to be delayed by three months. 

You must also permit insurance companies to access your CAQH profile. Otherwise, they can’t view or verify anything. 

Step 3: Choose Which Insurance Companies to Join 

Next, decide which insurance companies you want to get credentialed with. This depends on your patient population and specialty. 

Common options include: 

• Major commercial carriers like Aetna, Cigna, Humana, and UnitedHealthcare 
• Blue Cross Blue Shield (state-based affiliates like Anthem, CareFirst, etc.) 
• Medicare (federal, via the PECOS system) 
• Medicaid (state-specific—each state has its own portal and process) 
• Managed Care Organizations (MCOs) 
• Workers’ Compensation carriers and auto insurers 

A good strategy is to look at your competitors—or referring providers—and see which plans they accept. For example, if you’re a physical therapist in a city with a large union population, getting credentialed with workers’ comp insurers could be a game-changer. 

Step 4: Submit Enrollment Applications 

Each insurance company has its process; unfortunately, there’s no universal application. Some use CAQH exclusively; others require separate enrollment portals or downloadable forms. 

For each insurer, you’ll typically need to: 

• Fill out an application with demographic and practice details 
• Submit your CAQH ID and/or NPI 
• Upload required documents (W-9, malpractice insurance, etc.) 
• Indicate whether you’re applying as an individual or part of a group 

The application process can be time-consuming. Completing the necessary paperwork for a small clinic with five providers may require 15–20 hours, especially without a dedicated credentialing coordinator. Hospitals and group practices often assign this task to a credentialing coordinator or use a third-party service. But if you’re solo or small, set aside time and patience. 

If you’re managing this internally, document everything. One of our clients created a credentialing log using Google Sheets, but still missed two insurer follow-ups due to a lack of centralized oversight. A credentialing dashboard or matrix helps track deadlines, submitted documents, contact info, and follow-up dates.

Step 5: Wait for the Credentialing Process to Play Out 

Once your applications are submitted, the insurance companies will begin primary source verification. This means they’ll check every detail—from your medical school degree to your DEA license—to ensure it’s legit. They may also run background checks, verify your board certifications, and review your malpractice history. 

Then, your file goes to a credentialing committee for final approval. This could be a monthly meeting or a quarterly review. So, even if your paperwork is perfect, there’s still some waiting involved. 

Expect a timeline of 60 to 120 days for commercial insurance. Medicare can be faster, around 60–90 days, while Medicaid varies widely by state. 

Many insurance companies provide portals or phone support to track application status. Make it a habit to follow up every 2–3 weeks to ensure no delays or missing documents.

Step 6: Review and Sign the Insurance Contract 

Once you’re approved, you’ll receive a contract from the insurer. This is where the business side kicks in. 

The contract outlines:

• Your reimbursement rates 
• Effective dates 
• Billing procedures 
• Network participation details 
• Any restrictive clauses or termination policies 

Before you sign, review it carefully. For example, if you’re a behavioral health therapist, check if they reimburse for telehealth sessions. If you’re a surgeon, verify that assistant surgeon fees are included. You can often negotiate better rates, especially if your specialty is in demand. 

You’ll also want to note the effective date—the day you’re officially “in-network.” You can’t backdate claims. So if your first patient shows up on May 1st, but your contract starts May 15th, that first visit will be out-of-network. 

Step 7: Update Your Billing System and Start Seeing Patients 

Once credentialed, ensure your staff and billing team are in the loop. Update your electronic health record (EHR) system, billing software, and insurance verification tools with the new payer IDs and fee schedules. 

Run a few test claims or eligibility verifications to ensure everything is working. Train your front desk team to recognize which patients are covered under your new in-network contracts. 

This is crucial for smooth revenue cycle management. Many claims are denied simply because the wrong payer ID was used, or because a patient’s plan wasn’t verified upfront. 

How Long Does Credentialing Take?

As a provider or a medical practice owner, you must know the timeframe for the credentialing process.  

Here’s a rough estimate based on the type of payer: 

Payer	Timeline
Medicare	60–90 days
Medicaid	60–120 days
Commercial (Aetna, UHC, etc.)	90–120 days
MCOs	90–150 days

Keep in mind that delays are common. The clock resets if the insurance company finds a gap in your work history or your CAQH attestation has expired. 

Tips to Make Credentialing and RCM Easier

• Use Credentialing Software: Tools like Modio, MedTrainer, or Kareo can automate tracking and renewals
• Assign Responsibility: Dedicate a staff member or hire a credentialing coordinator 
• Track Expiration Dates: Licenses, DEA, and malpractice policies need updating
• Negotiate Contracts Annually: Don’t be afraid to renegotiate your rates
• Maintain an Insurance Matrix: Track which provider is in-network with which payers, along with effective dates
• Audit Your Credentialing Workflow Quarterly – We recommend a quarterly audit to ensure your practice isn’t exposed to risks. This includes checking credentialing statuses, payer enrollment logs, and re-credentialing deadlines.
• Use an Insurance Participation Matrix – At ANR Medical Billing, we create a matrix that maps each provider to payers, effective dates and renewal timelines. It’s simple but prevents most credentialing lapses.

What About Re-Credentialing? 

Credentialing isn’t a one-time thing. Most insurance companies require re-credentialing every 2 to 3 years. They’ll recheck your license, malpractice history, and other data. If you fail to respond, you could be dropped from the network. 

Make it part of your annual compliance review to check: 

• License renewals 
• CAQH attestations 
• Malpractice coverage 
• Expiring contracts 

Outsourcing the Credentialing Process 

If all of this sounds overwhelming—and for many, it is—there are professional credentialing services that handle everything for you. These are especially helpful for:

• New practices 
• Multi-state or multi-location groups 
• Hospitals are bringing on many new providers 

When you outsource, you’re not just paying for paperwork—you’re buying peace of mind. The right firm will also:

• Keep a live status tracker for each insurer
• Communicate directly with payers on your behalf
• Alert you before deadlines hit
• Help renegotiate unfavorable contract terms

Final Thoughts 

Credentialing is one of those behind-the-scenes tasks that can either make or break your practice financially. When done right, it leads to faster payments, fewer denials, and more patients walking through the door. When done poorly—or neglected—it can choke your revenue stream and create chaos in your billing department. 

So whether you’re an independent specialist, a hospital administrator, or the manager of a growing multi-specialty group, getting properly credentialed is one of the most important administrative tasks you’ll ever handle.