Frequently Asked Questions

Medical credentialing is the formal process of verifying a provider's qualifications, license, board certification and history so they can treat patients and join hospital staffs and insurance networks. The defining feature is primary source verification: every credential is confirmed straight from the body that issued it, not taken from the provider's word. For the full walkthrough, see what is medical credentialing.

Credentialing verifies that a provider is qualified. Payer enrollment registers and contracts that verified provider with a specific insurance plan so they are in network and claims get paid. Credentialing comes first, and you usually need both. We run the enrollment side through payer enrollment.

Credentialing confirms a provider is qualified in general. Privileging grants permission to perform specific procedures at a specific hospital. A facility credentials you first, then privileges you for the procedures you are trained to do.

Industry typical timelines run about 90 to 120 days from a clean application to an active payer panel, with an outer range of 60 to 180 days depending on the payer. Under NCQA rules effective July 1 2025, credentialing organizations must finish primary source verification within 120 days if accredited, or 90 days if certified. See the credentialing timeline and checklist.

Industry typical ranges are about 30 to 90 days for Medicare through PECOS, 30 to 60 days for Medicaid depending on the state, and 60 to 120 days for commercial payers like Aetna, Cigna, UnitedHealthcare, Humana and Blue Cross Blue Shield. Missing documents or unexplained gaps can stretch any of these out.

Generally no. You usually cannot bill a plan as an in network provider until you are credentialed and enrolled with it, and CMS requires it before Medicare or Medicaid reimbursement. Commercial payers rarely backdate, so care before your effective date often goes unpaid. Medicare allows retrospective billing for a limited window, up to 30 days prior in some cases.

Industry typical ranges put initial credentialing at roughly $1,500 to $3,000 per provider for a full payer set, or about $100 to $300 per provider for each individual payer, with monthly maintenance around $50 to $200. The biggest cost driver is the number of payers, since each is a separate application; specialty, current status and rework also move it. Those are general market ranges from public sources, not a fixed price, and exact pricing is quoted per engagement. See credentialing services cost.

CAQH does not charge providers a registration fee; the cost is the time to set the profile up and re attest. Medicare does charge an institutional application fee, set at $750 for calendar year 2026 by CMS, though individual physicians filing the CMS-855I generally do not pay it.

Medicare, through PECOS using the CMS 855 forms. Medicaid, where each state runs its own program, portal and rules, so a provider working in several states files several applications. And commercial plans, including Aetna, Cigna, UnitedHealthcare, Humana and Blue Cross Blue Shield, most of which pull their data straight from CAQH.

Contracting is the agreement inside enrollment: the payer sends a participation contract that sets your fee schedule and effective date, and signing it makes you in network. After that, EDI, ERA and EFT are set up so claims go out and payments come back electronically once you go live.

CAQH, the Council for Affordable Quality Healthcare, runs a single credentialing profile, CAQH ProView, now called the Provider Data Portal, that many health plans read. Most providers who bill commercial insurance need one, because plans like Aetna, Cigna, UnitedHealthcare, Humana and Blue Cross Blue Shield use it to credential providers. Registering and keeping a CAQH profile is free for providers. We build and maintain it through CAQH registration and maintenance.

Every 120 days, four times a year, even if nothing has changed. Providers in Illinois have a longer 180 day window. Miss the deadline and your profile shows as expired, which some payers read as a reason to drop you from the network. Have your NPI, issued by CMS through NPPES, in place before you register, since CAQH asks for it.

At minimum: your state license for every state you practice in, your NPI, DEA registration if you prescribe, board certification, a current CV with any gap explained, a malpractice insurance face sheet, a signed IRS W-9, education records, and a complete, attested CAQH profile. One organized folder saves weeks, since you supply the same items to every payer.

Most commercial payers recredential every 36 months, following the NCQA standard, and some Blue Cross Blue Shield state plans run a 24 month cycle. Medicare revalidation is every 5 years for most providers and suppliers, and every 3 years for DMEPOS suppliers. CAQH attestation, underneath all of it, is due every 120 days.

A lapse is costly. With Medicare it can deactivate your billing privileges and force a full re-enrollment rather than a quick fix; with commercial plans it can drop you from the network until you are re-approved. Managed recredentialing exists so that date never arrives unwatched.

We handle the work: building and attesting your CAQH profile, submitting applications to every payer, coordinating primary source verification, following up so your file does not sit in a queue, managing contracting and your effective date, setting up EDI, ERA and EFT, and tracking renewal deadlines. You supply your documents, signatures and payer list. See the full range of credentialing services. specific proof points — providers served, years in business, turnaround commitment

Want a real number instead of a range? Tell us your provider count, payers and states, and we will quote it itemized. Pricing is quoted per engagement, not off a fixed menu. company specific pricing, packages and any minimums

Prefer to talk it through? Call phone.

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*ProCred — national medical credentialing and payer enrollment for providers, groups and facilities across the United States.*