If you plan to treat Medicare or Medicaid patients, you must clear every CMS credentialing requirement first. Skip a step and you risk landing on the dreaded “red list,” which means zero reimbursement. Relax, though: credentialing is not rocket science. Think of it as brewing your morning coffee—simple, but you still need the right steps.

In this guide, you will learn about:

• Provider enrollment basics (PECOS, CMS-855I, CMS-855B)
• Medicare and Medicaid credentialing checklists
• Telemedicine credentialing rules for virtual visits
• Delegated credentialing and how large groups speed things up

As a medical billing specialist, I have helped thousands of clinics move from pending to paid status without a single denial. You can do the same. Follow along and see how to:

• Build a spotless CAQH profile
• Avoid common credentialing denials
• Keep your NPI linked to the correct taxonomy code
• Meet every re-credentialing deadline

Have questions like “How do I join Medicare as a new provider?” or “What is the fastest way to update PECOS?” They are answered here. By the end, you will know exactly what CMS expects, which forms to file, and how to stay on the green list so your healthcare claims get paid in full and on time.

CMS Credentialing Requirements for Healthcare Providers in the USA

CMS (Centers for Medicare & Medicaid Services) credentialing requirements refer to the processes and standards that healthcare providers must meet in order to be approved for participation in Medicare and Medicaid programs. 

Some of the basic requirements are:

1). Obtain Your National Provider Identifier (NPI)

The initial step in the CMS credentialing process is obtaining your NPI number. It is a 10-digit identifier utilized for all healthcare billing, including payment for Medicare and Medicaid. You will not be able to send in or get reimbursed for any claims if you do not have it.

Application for your NPI is possible through the National Plan and Provider Enumeration System (NPPES). The application involves basic information such as your name, practice address, tax ID, contact information, license, and credentials.

The majority of healthcare professionals register for the NPI first, since they will also require it during later PECOS registration and CMS enrollment.

Having an NPI is among the most usual prerequisites for any medical billing operation. It ensures that CMS and payers are able to track who is offering the services, particularly for specialties such as family medicine, behavioral health, or physical therapy.

2). Ensure Your License is Current and Validated

You will need a current and unrestricted license to practice in the state in which you will be treating patients. CMS will not accept an expired or restricted license, and they will check for this information when you are enrolling.

Depending on your provider type, you may also be asked to furnish proof of board certification or further training. For instance, some positions, such as cardiologists or nurse anesthetists, will require additional credentials.

The CMS also cross-checks the Office of Inspector General (OIG) List of Exclusions. In case you have participated in healthcare fraud, abuse, or other disqualifying conduct, you will be excluded from participation in Medicare. This is done to make sure that nothing but eligible health care providers are permitted to charge Medicare and Medicaid.

3). Fill out the CMS Enrollment Forms or Use PECOS

Once your licensure and NPI are verified, the following step is to formally enroll in Medicare. You may do this by filing the respective CMS-855 form or by enrolling online through PECOS, or Provider Enrollment, Chain, and Ownership System.

Every form has a particular function:

• Individual healthcare providers, such as physicians, therapists, and nurses, use CMS-855I.
• The CMS-855B is utilized for group practices and clinics.
• CMS-855A is for institutional providers, including hospitals and nursing facilities.
• CMS-855R is for reassigning Medicare benefits to an entity, such as a group or an organization.

PECOS is the most popular choice among providers as it enables quicker submission and immediate tracking of application status. Filing the incorrect form or omission of documentation will hold up your credentialing process by a great deal, hence you need to do this step with care.

4). Credentialing by a Medicare Administrative Contractor (MAC)

During CMS enrollment, every provider passes through a Medicare Administrative Contractor for review. A MAC is a private firm that manages Medicare enrollment, handles claims processing, and verifies provider credentials within its region.

A MAC checks your forms, confirms your license, and makes sure every supporting document is in place. If something is missing, you receive a request for more information instead of a flat denial. Processing times vary by region, so keep local timelines in mind.

When the MAC approves your file, CMS issues a Provider Transaction Access Number (PTAN). You will need this PTAN whenever you submit Medicare claims or update your record in PECOS.

Smooth MAC credentialing sets the stage for trouble-free billing with Medicare beneficiaries.

5). Medicare Participation Agreement

After credentialing, CMS asks you to sign a Medicare Participation Agreement. This short contract spells out what you agree to when you treat Medicare patients.

• You follow all CMS regulations, including coding rules, reimbursement limits, and fraud-prevention policies.
• You accept the Medicare fee schedule as full payment, except for allowed coinsurance or deductibles.
• You send clean claims on time and bill only for medically necessary services.
• You maintain quality-of-care standards, which CMS may audit through its quality reporting programs.

Once the agreement is on file, you can begin seeing Medicare patients and submitting electronic claims without delay.

6). Ongoing Compliance with Federal and State Rules

CMS approval is not the finish line. Providers must stay current with both federal regulations and state requirements to keep billing privileges active.

➜ Federal rules

• Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• HIPAA privacy and security safeguards
• Policies in the Affordable Care Act that affect provider enrollment
• Current CMS billing and coding guidelines

These standards apply to physicians, therapists, hospitals, home health agencies, and every other Medicare-enrolled entity.

➜ State rules

• Professional licensure laws require an active, unrestricted license in each state where you practice.
• Scope-of-practice statutes limit which services your license allows you to perform.
• Each state Medicaid program has its own enrollment steps that build on federal guidance.
• Managed Care Organizations (MCOs) may add extra credentialing checks before they will contract with you.
• State privacy laws, such as California’s CCPA, can be stricter than HIPAA.
• If you deliver telehealth, you must follow every state’s telemedicine and cross-state licensure rules.

Meeting these federal and state obligations helps you avoid claim denials, overpayment recoupments, and potential exclusion from government programs.

7). Clear Background Check

CMS only accepts providers whose records are clean. During both initial credentialing and the three-year recredentialing cycle, CMS runs a background check that looks at professional qualifications, criminal history, and any past Medicare fraud or abuse. Failing this review can delay or deny enrollment, revoke billing privileges, and trigger legal or financial penalties.

What CMS reviews:

• Criminal convictions at the federal or state level
• Medicare and Medicaid exclusion lists
• License status plus any disciplinary actions
• Malpractice claims and settlements
• Education, training, and residency verification

8). Malpractice Insurance Requirements

Every provider must carry active malpractice (professional liability) insurance to protect patients and themselves against errors or negligence claims. CMS checks coverage at enrollment, at recredentialing, and during random audits.

• Most plans require at least one million dollars per claim and three million dollars aggregate each year, although limits can vary by state or specialty
• A current Certificate of Insurance (COI) must list the insured name, policy number, coverage dates, limits, and carrier
• Providers changing jobs or retiring may need tail coverage to insure prior acts

Without proof of adequate coverage, CMS can deny enrollment or terminate participation.

9). Meeting CMS Quality Standards

CMS expects all enrolled professionals and facilities to deliver safe, effective, and high-quality care. Compliance is also tied to value-based payment models.

Key quality checkpoints:

• Adhering to Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• Reporting through MIPS if eligible
• Tracking and submitting Clinical Quality Measures (CQMs)
• Failure to meet these benchmarks can reduce reimbursement or trigger corrective action plans.

10). Provider-Specific Rules

CMS tailors requirements to the provider’s role.

• Pharmacists, physician assistants, and other non-physician practitioners may need proof of specialty certification or documented supervision
• Telemedicine professionals must hold a valid license in each state where patients are located and meet state-specific virtual-care rules

11). Additional Certifications CMS May Require

Depending on services offered, you might need extra credentials alongside standard Medicare enrollment.

12). Site Visits and Operational Standards

CMS may conduct on-site inspections during initial enrollment, revalidation, or whenever red flags arise. Inspectors confirm that:

• The office address on your application physically exists and matches signage
• Posted hours are accurate and staff are present
• Patient-care areas, record storage, and equipment meet health and safety rules
• Policies align with HIPAA, infection control standards, and local building codes

Passing the site visit proves that your practice is real, operational, and ready to serve Medicare and Medicaid beneficiaries.

CMS Telemedicine Credentialing Requirements

Telemedicine follows the same core CMS enrollment rules as in-person care, yet it adds a few extra layers that reflect the unique, screen-to-screen setting. Providers who plan to deliver virtual visits to Medicare or Medicaid patients must meet each standard below to secure reimbursement and avoid claim denials.

Here are the key CMS telemedicine credentialing requirements:

Provider Enrollment

• Complete the correct CMS-855 application and choose the telemedicine service type when prompted.
• Submit your National Provider Identifier (NPI), proof of active license, malpractice coverage, and any state-specific forms.
• Keep your information current in PECOS so payers can verify your status before processing remote-care claims.

Licensure Across State Lines

• Hold an active license in the state where the patient sits during the visit, even if you live elsewhere.
• Many providers rely on the Interstate Medical Licensure Compact or similar nursing and psychology compacts to speed up multi-state approval.
• Track renewal dates carefully; an expired out-of-state license can halt payment for every virtual visit.

HIPAA-Compliant Technology

• Use a HIPAA-compliant telemedicine platform for video, chat, and file sharing.
• Encrypt data in transit and at rest, maintain audit logs, and restrict user access to the minimum necessary.
• Provide patients with the standard Notice of Privacy Practices that explains how their data is stored and shared.

State and Federal Telemedicine Rules

• Follow your state’s practice standards, prescribing limits, and modality restrictions for virtual care.
• Some states enforce payment parity laws that require commercial plans to cover telehealth at the same rate as face-to-face visits; CMS often mirrors these rules for Medicaid.
• Document each visit just as thoroughly as an in-office encounter, including location of patient and provider.

Patient Consent

• Obtain informed telehealth consent before the first virtual session of the patient.
• Explain how the service works, any technology risks, and steps taken to secure data.
• Keep a signed or electronically acknowledged consent form on file, as CMS may request it during audits.

Supervision and Delegation

• If nurse practitioners, physician assistants, or other clinicians deliver remote care, meet CMS and state supervision or collaboration requirements.
• Clearly outline who can provide which services, how oversight is documented, and how escalation to a supervising physician occurs.

CMS Delegated Credentialing Requirements

Sometimes a health plan or large provider group lets a separate entity handle day-to-day credentialing. This is known as delegated credentialing and it comes with its own set of CMS rules. Even when the work is handed off, the original organization is still responsible for meeting every CMS standard.

Here are the key CMS delegated credentialing requirements:

Formal Delegation Agreement

A clear, written agreement must be in place before any work starts. The document should

• list every task the delegate will complete, such as primary-source verification or final credentialing decisions
• spell out performance targets and how results will be reported
• describe how the delegating organization will monitor, audit, and if needed, cancel the arrangement
• require the delegate to follow NCQA or an equivalent set of credentialing standards when the health plan is NCQA-accredited

Oversight and Accountability

The health plan—or other delegating group—keeps full responsibility for compliance. To show CMS that proper oversight exists, the plan must

• review and approve the delegate’s policies and procedures before work begins
• audit the delegate, usually once a year, to confirm rules are being followed
• maintain written records of every review, audit, and corrective action
• step in quickly if audits reveal non-compliance

Credentialing Standards to Maintain

The delegate has to apply all routine credentialing checks, including primary-source verification of

• active state license and any required specialty license
• DEA certificate if the provider prescribes controlled substances
• board certification when the specialty calls for it
• education, training, and recent work history
• current malpractice insurance with adequate limits
• sanctions, disciplinary actions, and the OIG exclusion list

These safeguards ensure every provider in the network is licensed, competent, and in good standing.

Revoking or Correcting Delegation

If audits show that credentialing standards are not met, the health plan must

• issue a corrective action plan with clear deadlines
• revoke the delegation if problems persist
• resume direct credentialing in-house or choose a new, compliant delegate

By keeping a close eye on every delegated activity, the health plan protects patients and stays aligned with all CMS credentialing regulations.

FAQs

What is CMS credentialing and why does it matter?

CMS credentialing is the process that confirms a provider’s identity, professional qualifications, and compliance record before allowing Medicare or Medicaid billing. Without it, claims will be rejected and you cannot treat covered patients.

Which core documents do I need to start a CMS application?

You will need an active state license, National Provider Identifier (NPI), malpractice insurance certificate, work history, education and training records, and a completed CMS-855 application (or the PECOS online equivalent).

How long does initial credentialing for CMS usually take?

Most clean applications pass through a Medicare Administrative Contractor in thirty to ninety days. Missing paperwork, pending license renewals, or background issues can extend the timeline.

How often must I complete CMS recredentialing or revalidation?

CMS requires recredentialing every three years for all enrolled providers. A separate revalidation notice can arrive sooner if you move, change ownership, or trigger other risk factors.

What is the difference between a CMS-855 paper form and PECOS?

CMS-855 is the paper enrollment packet. PECOS is the secure online portal that lets you fill out the same information electronically, upload documents, and track your application status. Use one method per enrollment cycle.

Can my practice delegate CMS credentialing to a Credentialing Verification Organization (CVO)?

Yes. A formal delegation agreement must spell out the CVO’s duties, performance standards, audit schedule, and termination clauses. Even with delegation, your organization remains accountable for meeting every CMS rule.

Does CMS perform site visits and why?

Yes. CMS or its contractor can conduct a site visit during initial enrollment, revalidation, or when they detect billing anomalies. Inspectors verify that the listed address exists, hours are posted, staff are present, and records are secure.

Do I need a separate state license for each location where patients are treated, including telehealth?

Yes. You must hold an active license in every state where the patient is located at the time of service. This applies to both in-person care and telemedicine appointments.

How long does it take to get credentialed with insurance companies and why?

The average time it takes for providers to get credentialed is between 90 to 120 days (and up to 180 days in some cases). Some insurance companies process applications faster, while others may take longer, especially for certain specialties.

So, the time frame varies significantly, depending on tons of factors. We’ll talk about them in detail as you scroll through.

The Timeline for Provider Credentialing Process

The credentialing process for healthcare providers with insurance companies involves several key steps, each taking a specific amount of time.

Here’s a detailed timeline breakdown of the credentialing process.

1. Preparing Documentation (1-2 Weeks)

The initial step involves collecting all necessary documents that may take 1-2 weeks. A credentialing specialist can review these documents thoroughly who also conducts primary source verification to ensure accuracy.

Providers should prepare a checklist to streamline this phase.

Application: General information including personal details, contact information, and professional background.

Education: Documentation of education such as diplomas, specialty certificates, and additional qualifications.

Licenses and Certifications: Copies of current and valid medical licenses, board certifications, and registrations.

Work History: Detailed account of previous positions, dates of employment, and responsibilities.

Malpractice Insurance: Proof of malpractice or liability insurance coverage.

References: Professional references from colleagues, supervisors, or mentors.

DEA Registration: Drug Enforcement Administration registration details for prescribing controlled substances.

Personal Identification: Valid identification documents like a driver’s license, passport, or social security number.

Background Check: Verification of criminal records and/or disciplinary actions.

Credential Evaluation: Assessment against the organization’s specific criteria.

Preparing and gathering necessary documentation helps streamline the credentialing process and avoid delays.

2. Submitting Applications (1-2 Weeks)

After gathering documents, providers fill out application forms for getting credentialed with insurance companies. This step includes gathering personal details, filling in required information, reviewing for accuracy, and submitting the applications. Generally, it takes 1-2 weeks, but using robust credentialing software speeds up the process.

• Get personal, professional, and supporting documents (1-2 Days).
• Fill out the application forms and start leveraging software (3-5 Days).
• Proofread and review the entire application once again (1-2 Days).
• Submit the application with methods specified by insurance companies (1-2 Days).
• Track submissions, respond to requests, and follow up with the insurance companies (ongoing).

Using the right tools and strategies helps you manage, complete and submit applications effectively within the 1-2 week timeframe.

3. Primary Source Verification (4-6 Weeks)

During this crucial phase, insurance companies verify credentials directly with educational institutions, licensing boards, and previous employers. This credentialing step ensures the accuracy and authenticity of the provider’s qualifications.

The time frame can vary depending on the responsiveness of the institutions and agencies involved. But generally, it takes around 4-6 weeks. You can do nothing about it, just make sure you give accurate information and truthful documentation.

4. Insurance Company Review (4-8 Weeks)

Once verification is complete, the insurance company reviews the application in detail. This includes checking compliance with their internal standards. The time frame is usually 4-8 weeks but can vary based on the thoroughness of their review process.

The insurance company reviews the application, assessing the provider’s qualifications, experience, and background. The process may include:

• Application Assessment
• Compliance Check
• Background Verification
• Internal Review Timelines

Delays can occur if the insurance company needs further clarification or if there are issues with the documentation provided. It can also take long if the insurance company’s internal review committees meet less frequently.

5. Board or Committee Approval (1-2 Weeks)

The application is then presented to a credentialing committee or board, which meets monthly or bi-monthly. It evaluates all findings and makes a decision on the provider’s credentialing status.

The timing of the next available meeting can influence how quickly the application is reviewed. But usually, this step in the provider credentialing process takes 1 to 2 weeks approximately. You cannot do anything to expedite the process.

The credentialing committee typically includes healthcare professionals and administrative staff, and it reviews the application in detail. They assess qualifications, experience, and findings from the background checks and compliance reviews.

After the committee review, the members raise concerns and talk about the provider’s suitability for inclusion in the network. And then, they vote on whether to approve, deny the application, or request some more information.

If approved, you’re done with the initial credentialing process and get in-network with the insurance. But if the additional information is required, the process gets extended until the next committee meeting.

6. Contracting and Enrollment (2-4 Weeks)

After approval, you as a healthcare provider will receive and review a contract outlining participation terms. You can negotiate before signing. Once signed, you are officially enrolled in the insurance network.

The insurance company updates their systems to include you as a new provider in their network. This ensures that patients and other stakeholders can see that the provider is now part of the network. The provider receives a notification confirming their enrollment.

This step in credentialing typically takes 2-4 weeks to complete, depending on the efficiency of both the provider and the insurance company.

In total, the entire credentialing process can take between 12 to 24 weeks (approximately 3 to 6 months), depending on these factors:

• The completeness of the application.
• The responsiveness of third-party verification sources.
• And internal processing times of the insurance company.

But why does the credentialing take ages? Let us answer that!

Why Does Provider Credentialing Take So Long?

As a healthcare provider, you’ve jumped through all the hoops – submitting your application, paying fees, providing documents – to get credentialed. But instead of the few weeks you expected, it’s been months, and your insurance credentialing status is still stuck in limbo. What gives?

You’re not the problem. The snail’s pace is by design on the insurers’ part.

Insurance companies follow a lengthy, rigorous credentialing process to vet every provider before allowing them to join their network. This involves verifying your qualifications, work history, malpractice coverage, and other aspects that affect your ability to deliver safe, quality care. They must comb through primary source verifications, license checks, and other certifications.

So while frustrating for providers, the long credentialing timeframe stems from the insurer’s due diligence. For you, it means playing the waiting game.

Here’s an overview of what contributes to these delays.

Extensive Verification

Credentialing requires thorough verification of a provider’s education, training, licenses, certifications, work history, and malpractice records. This process involves contacting multiple institutions, which can take time.

Primary Source Verification

Each piece of information must be confirmed directly with original sources, such as medical schools, licensing boards, and other institutions. This step ensures accuracy but lengthens the timeline of provider credentialing.

Background Checks

Comprehensive background checks, including criminal history and malpractice verification, are crucial for patient safety. These checks can take considerable time to complete, making sense of prolonged credentialing timeframe.

Committee Reviews

Credentialing committees need to review and approve applications. Delays can occur if there are scheduling conflicts or backlogs of applications in the review process.

Incomplete Applications

Missing or incorrect information in a provider’s application can cause significant delays. Requests for additional documentation or corrections can add weeks or even months.

Lack of Standardization

Different healthcare facilities may have varying requirements and processes for credentialing. There’s no standardization and this creates redundancy and inefficiencies, prolonging the process.

High Volume of Providers

When many providers are seeking credentialing at the same time, backlogs can develop, slowing down the overall process.

Response Times from Institutions

Delays can occur if educational institutions or previous employers take too long to respond to verification requests. A slow response can add weeks to the provider credentialing timeline.

Discrepancies in Documentation

Additional follow-ups are required if there are discrepancies in the information provided. Investigating these issues can significantly extend the credentialing process.

Scheduling Conflicts

If the credentialing board has a busy schedule, it may take longer to get applications reviewed and approved.

Internal Processing Delays

The insurance company or healthcare facility may have internal processing delays due to staffing, policy changes, or procedural bottlenecks.

Tips to Speed Up Insurance Credentialing Process

To expedite the credentialing process, providers must start the process earlier, use robust software, establish a clear workflow, set reminders for follow-up, and hire a good healthcare credentialing company.

Streamline Documentation

To speed up the insurance credentialing process, healthcare providers can follow these steps to improve how they handle and submit their application documents:

➜ Organize Your Documents: Create a list of all the documents you need, like insurance information, licenses, and certificates. Put them in a special folder so you can get to them easily.

➜ Use Standard forms: Submit documents in widely accepted formats (like PDF). This reduces confusion and makes it easier for insurance companies to review your materials.

➜ Double-Check Everything: Make sure all of your documents are complete and accurate before sending them in. Delays can happen when information is missing or wrong.

➜ Digital Submission: Whenever possible, submit applications and documents electronically. This speeds up the process and reduces the risk of lost paperwork.

➜ Follow Up: Once you’ve sent your documents to the insurance company, call them again to make sure they got them and to find out what’s going on with your application.

Conduct Pre-Credentialing Reviews

Conducting pre-credentialing reviews is an effective way to speed up the credentialing process. By taking proactive steps, you can ensure that everything is in order before submitting applications.

➜ Use Pre-Screening Checklists:

• Develop checklists that list all the necessary documents and information needed for credentialing.
• Check these lists to identify any missing items or potential issues before you submit the application.

➜ Hold Mock Credentialing Sessions:

• Conduct practice sessions that simulate the credentialing process.
• Use these sessions to spot any bottlenecks or problems that might slow down the process.

Engage a Credentialing Service

As a healthcare worker, you can get outside help to speed things up if you need to.

Using third-party companies that offer credentialing services is one strategy. These businesses already have systems in place and connections with payers that make the credentialing process go faster. As part of their routine work, they fill out forms, check papers, and follow up with insurance companies. Because of this, you will be able to focus more on each patient.

Working together with a Managed Service Organization (MSO) is another choice. MSOs offer full credentialing support as one of their many services. Some of the things they do to help you get accepted are talking to payers, filing claims, negotiating contracts, and managing the medical revenue cycle. This all-around service makes sure that your credentials are always up-to-date and that you get paid quickly for your claims.

Strengthen Relationships with Payers

Healthcare providers should focus on building better connections with payers to speed up the insurance credentialing process. This means keeping in regular contact with payer officials and quickly informing them about any changes that could affect credentialing.

Here are some key areas for providers to focus on:

• ➜ Talk Directly to Payer Staff: Reach out to the payer credentialing team. This can help clarify any confusing requirements and ensure you understand what’s needed. Having a specific contact person can also make it easier to check on the status of your applications and resolve any issues that might delay acceptance.
• ➜ Keep Payers Updated: It’s important to inform payers about any changes to your details. This includes updates to credentials, locations, affiliations, licenses, and more. By giving timely notice, payers can quickly update their records, which helps prevent administrative hiccups that could slow down the process.

By sharing clear information and delivering frequent updates, providers can groove their way to solid relationships with payers. This not only jazzes up the credentialing process but also lets providers get the green light faster, so they can jump right into caring for patients with insurance coverage.