Insurance Credentialing Made Simple: What to Do First, Who to Apply With, and How to Avoid Delays

Insurance credentialing is one of the most frustrating parts of starting a practice. The process is slow, bureaucratic, and confusing—but it's essential if you want to accept insurance.

This comprehensive guide walks you through every step: CAQH setup, choosing which insurance companies to apply with, realistic timelines, and how to avoid the common mistakes that delay credentialing by months.

What is Insurance Credentialing?

Definition: Credentialing is the process of getting approved to be an in-network provider with insurance companies. Once credentialed, you can bill insurance directly and patients can use their benefits with you.

What It Involves:

• Verifying your education and training
• Checking your licenses and certifications
• Reviewing your work history
• Confirming malpractice insurance
• Background checks
• DEA verification (if prescribing)
• Board certification verification

Why It Matters:

• Can't bill insurance without it
• Patients can't use in-network benefits
• Lose 3-6 months of potential revenue during process
• Required for most insurance-based practices

Timeline:

• CAQH setup: 1-2 weeks
• Insurance credentialing: 90-180 days per company
• Total time to first payment: 4-7 months

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Step 1: Set Up Your CAQH Profile

What is CAQH?

CAQH (Council for Affordable Quality Healthcare) is a centralized database that stores your credentialing information. Most insurance companies use CAQH to verify providers, so you only need to enter your information once.

Who Uses CAQH:

• Most major insurance companies
• Medicare (in some states)
• Medicaid (in some states)
• Managed care organizations

Cost:

• Free for providers
• Insurance companies pay for access

CAQH Setup: Step-by-Step

Step 1: Create Account (30 minutes)

1. Go to https://proview.caqh.org

2. Click "Register"

3. Enter basic information:

   • Name
   • Date of birth
   • SSN
   • NPI number (get this first if you don't have it)
   • Email
   • Phone

4. Create username and password

5. Verify email

Step 2: Complete Profile (4-6 hours)

Personal Information:

• Legal name
• Date of birth
• SSN
• Gender
• Home address
• Contact information

Education:

• Medical/nursing/graduate school
• Dates attended
• Degree earned
• Graduation date
• Upload diploma

Training:

• Residency (if applicable)
• Fellowship (if applicable)
• Internship
• Dates
• Program director contact
• Upload certificates

Licenses:

• All state licenses
• License numbers
• Issue and expiration dates
• Upload license copies
• Disciplinary actions (if any)

Board Certification:

• Specialty
• Certifying board
• Certificate number
• Issue and expiration dates
• Upload certificate

Work History:

• Last 5 years (minimum)
• All positions
• Dates
• Supervisor contact
• Reason for leaving
• Gaps explained

Hospital Privileges:

• Current privileges
• Hospital name
• Department
• Dates
• Upload privilege letters

Malpractice Insurance:

• Insurance company
• Policy number
• Coverage amounts
• Effective dates
• Upload certificate
• Claims history (if any)

DEA (if prescribing):

• DEA number
• Issue and expiration dates
• Upload DEA certificate

References:

• 3 professional references
• Names, titles, contact info
• Relationship to you
• How long they've known you

Step 3: Upload Documents

Required Documents:

• Medical/nursing school diploma
• Residency/fellowship certificates
• All state licenses
• Board certification
• DEA certificate
• Malpractice insurance certificate
• CV/resume
• Photo ID
• Voided check (for EFT)

Document Requirements:

• Clear, legible scans
• PDF format preferred
• Current (not expired)
• Official copies
• Color scans for licenses

Step 4: Attest and Submit

1. Review all information carefully
2. Check for errors or typos
3. Ensure all dates are correct
4. Verify all documents uploaded
5. Click "Attest"
6. Submit for review

Important: Attesting means you're certifying that all information is true and accurate. False information can result in denial or termination.

Step 5: Monitor Status

• CAQH reviews within 2-5 business days
• Check for "Incomplete" status
• Respond to requests immediately
• Re-attest every 120 days (required)

Common CAQH Mistakes to Avoid

Mistake 1: Incomplete Work History Problem: Gaps in employment or missing positions Solution: Account for every month of last 5 years, explain gaps

Mistake 2: Expired Documents Problem: Uploading expired licenses or certificates Solution: Ensure all documents are current before uploading

Mistake 3: Typos in Names/Dates Problem: Name on diploma doesn't match current name Solution: Double-check all names and dates match exactly

Mistake 4: Missing Attestation Problem: Forgetting to re-attest every 120 days Solution: Set calendar reminder for every 110 days

Mistake 5: Poor Quality Scans Problem: Blurry or illegible documents Solution: Use high-quality scanner, ensure text is readable

Mistake 6: Not Responding to Requests Problem: Missing CAQH requests for additional information Solution: Check email daily, respond within 24 hours

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Step 2: Get Your NPI Number

What is an NPI?

NPI (National Provider Identifier) is a unique 10-digit number that identifies you as a healthcare provider. Required for all insurance billing.

Types:

• Type 1 (Individual): For individual providers
• Type 2 (Organization): For group practices, clinics, hospitals

Cost: Free

How to Get Your NPI

Step 1: Apply Online

1. Go to https://nppes.cms.hhs.gov
2. Click "Apply for NPI"
3. Complete application (30-45 minutes)
4. Submit

Step 2: Receive NPI

• Issued immediately online
• Confirmation letter mailed within 10 days
• Save your NPI number

Information Needed:

• Legal name
• Date of birth
• SSN
• State license number
• Practice address
• Taxonomy code (specialty)

Timeline: Immediate (online) or 10 days (by mail)

Common NPI Mistakes

Mistake 1: Wrong Taxonomy Code Problem: Selecting incorrect specialty code Solution: Use NUCC taxonomy code lookup tool

Mistake 2: Wrong Address Problem: Using home address instead of practice address Solution: Use address where you'll see patients

Mistake 3: Not Updating Problem: Moving offices but not updating NPI Solution: Update NPI within 30 days of any changes

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Step 3: Choose Which Insurance Panels to Join

Prioritize by Market Share

Research Your Market:

1. Ask colleagues which insurance they accept
2. Survey potential clients about their insurance
3. Check insurance company websites for provider counts
4. Look at local demographics

Typical Market Leaders (Varies by State):

National Plans:

• Blue Cross Blue Shield — Usually #1 or #2 in most states
• UnitedHealthcare — Large national presence
• Aetna — Strong in many markets
• Cigna — Good commercial coverage
• Humana — Strong Medicare Advantage

Regional Plans:

• Kaiser Permanente (CA, OR, WA, CO, etc.)
• Anthem (multiple states)
• Highmark (PA, WV, DE)
• Independence Blue Cross (PA)
• Premera (WA, AK)

Government Plans:

• Medicare — Required for 65+ population
• Medicaid — Varies by state, lower reimbursement
• Tricare — Military families

Reimbursement Rates by Insurance

High-Paying Plans (Typically):

• Blue Cross Blue Shield PPO
• Aetna PPO
• Cigna PPO
• UnitedHealthcare PPO
• Private insurance plans

Medium-Paying Plans:

• Blue Cross Blue Shield HMO
• Medicare
• Medicare Advantage plans
• Some regional plans

Low-Paying Plans:

• Medicaid
• Some Medicare Advantage plans
• Some regional HMOs

Example Reimbursement (Therapy Session):

• BCBS PPO: $100-120
• Aetna PPO: $90-110
• Medicare: $80-90
• Medicaid: $40-60

Strategy: Start with 2-3 high-paying plans, add more later if needed.

Recommended Starting Panels

For Most Providers:

1. Blue Cross Blue Shield — Largest market share in most states
2. Medicare — Required for 65+ population
3. Aetna or UnitedHealthcare — Second major commercial plan

For Mental Health:

1. Blue Cross Blue Shield
2. Aetna (strong mental health network)
3. Cigna (good mental health coverage)
4. Medicare (if seeing 65+)

For Primary Care:

1. Blue Cross Blue Shield
2. Medicare
3. UnitedHealthcare
4. Aetna
5. Medicaid (if serving low-income)

Don't Apply to All Plans:

• Start with 2-3 plans
• See which ones send most referrals
• Add more later if needed
• Quality over quantity

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Step 4: Apply for Credentialing

Application Process

Step 1: Contact Insurance Company

Find Credentialing Department:

• Call provider services number
• Ask for "credentialing" or "provider enrollment"
• Get direct contact information
• Ask about application process

Questions to Ask:

• Do you use CAQH or separate application?
• What additional documents do you need?
• What's the typical timeline?
• Is there an application fee?
• Who do I contact with questions?

Step 2: Complete Application

CAQH-Based Application:

• Insurance pulls info from CAQH
• May need supplemental forms
• Upload additional documents
• Sign and submit

Separate Application:

• Complete insurance-specific application
• Provide all documents again
• May be paper or online
• Sign and submit

Step 3: Submit Required Documents

Standard Documents:

• CAQH attestation (if CAQH-based)
• W-9 form
• Malpractice insurance certificate
• State license copies
• DEA certificate (if prescribing)
• CV/resume
• Voided check (for EFT)
• Signed contract

Additional Documents (Sometimes):

• Hospital privileges
• Board certification
• Specialty training certificates
• References
• Photo ID
• Proof of address

Step 4: Sign Contracts

Review Carefully:

• Reimbursement rates
• Contract length
• Termination clauses
• Billing requirements
• Documentation requirements
• Timely filing limits

Negotiate (If Possible):

• Some plans negotiate rates
• Usually only for high-demand specialties
• Group practices have more leverage
• Solo practitioners have less leverage

Step 5: Wait for Approval

Timeline:

• 90-180 days typical
• Some faster (60 days)
• Some slower (6-12 months)
• Follow up every 2-3 weeks

Status Checks:

• Call credentialing department
• Ask for status update
• Document who you spoke with
• Note any issues or delays

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Realistic Timelines

Month-by-Month Breakdown

Month 1: Setup

• Week 1: Get NPI number
• Week 2-3: Complete CAQH profile
• Week 4: Gather all documents

Month 2: Applications

• Week 1-2: Apply to first insurance company
• Week 3-4: Apply to second insurance company

Month 3-4: Waiting

• Follow up every 2 weeks
• Respond to any requests immediately
• Continue seeing private pay clients

Month 5-6: Approvals Start

• First approvals come through
• Effective dates set
• Can start billing insurance

Month 7: First Payments

• Submit first claims
• Wait 30-60 days for payment
• First insurance revenue

Total Timeline: 6-7 months from start to first payment

Factors That Affect Timeline

Faster Credentialing:

• Complete CAQH profile
• All documents current and uploaded
• No gaps in work history
• No disciplinary actions
• Respond to requests immediately
• High-demand specialty
• Provider shortage area

Slower Credentialing:

• Incomplete CAQH profile
• Missing or expired documents
• Gaps in work history
• Disciplinary actions
• Slow to respond to requests
• Saturated market
• New graduate

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How to Avoid Delays

Common Delays and Solutions

Delay 1: Incomplete CAQH Profile Problem: Missing information or documents Solution: Complete 100% of CAQH before applying Time Lost: 2-4 weeks

Delay 2: Expired Documents Problem: License or malpractice insurance expired Solution: Renew before expiration, upload immediately Time Lost: 2-6 weeks

Delay 3: Work History Gaps Problem: Unexplained gaps in employment Solution: Account for every month, explain gaps Time Lost: 2-4 weeks

Delay 4: Name Mismatches Problem: Name on diploma doesn't match current name Solution: Provide legal name change documentation Time Lost: 2-4 weeks

Delay 5: Not Responding to Requests Problem: Missing credentialing requests for info Solution: Check email daily, respond within 24 hours Time Lost: 2-8 weeks

Delay 6: Wrong Specialty Code Problem: Taxonomy code doesn't match training Solution: Use correct NUCC taxonomy code Time Lost: 2-4 weeks

Delay 7: Missing Malpractice Insurance Problem: No malpractice insurance or wrong coverage Solution: Get proper coverage before applying Time Lost: 2-6 weeks

Delay 8: Closed Panels Problem: Insurance not accepting new providers Solution: Check panel status before applying Time Lost: Indefinite (can't join)

Proactive Strategies

Strategy 1: Start Early

• Begin CAQH 6 months before opening
• Apply for credentialing 4-5 months before opening
• Have everything ready before you need it

Strategy 2: Use Credentialing Service

• Hire credentialing specialist ($500-2,000)
• They handle all paperwork and follow-up
• Faster, less stressful
• Worth it for most providers

Strategy 3: Follow Up Religiously

• Call every 2 weeks for status
• Document all conversations
• Be polite but persistent
• Escalate if needed

Strategy 4: Have Backup Plan

• See private pay clients while waiting
• Offer superbills for out-of-network
• Don't rely on insurance revenue initially
• Have 6 months expenses saved

Strategy 5: Join Group Practice

• Group practices often have faster credentialing
• Leverage existing contracts
• Less paperwork
• Faster revenue

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After Credentialing: Next Steps

Verify Your Credentialing

Check Insurance Directories:

• Search for yourself on insurance websites
• Verify information is correct
• Update if needed
• May take 30-60 days to appear

Get Effective Date:

• Ask for official effective date
• This is when you can start billing
• Can't bill for services before this date
• Document for your records

Set Up Billing:

• Get payer ID numbers
• Set up in EHR (ClinikEHR)
• Test claim submission
• Verify ERA/EFT setup

Start Billing Insurance

First Claims:

• Start with simple cases
• Verify eligibility before service
• Document thoroughly
• Submit claims within 24-48 hours

Monitor Claims:

• Check claim status weekly
• Follow up on denials immediately
• Track payment timelines
• Identify patterns

Optimize Revenue Cycle:

• Submit claims promptly
• Follow up on unpaid claims
• Appeal denials
• Track metrics

Maintain Credentialing

Re-Credentialing:

• Required every 2-3 years
• Insurance will notify you
• Update CAQH profile
• Submit new documents

Ongoing Requirements:

• Re-attest CAQH every 120 days
• Update any changes within 30 days
• Renew licenses before expiration
• Maintain malpractice insurance
• Report any disciplinary actions

Panel Status:

• Some panels close to new patients
• May need to reapply if dropped
• Maintain good standing
• Submit claims properly

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Credentialing Services: Worth It?

What Credentialing Services Do

Services Provided:

• Complete CAQH profile for you
• Apply to insurance companies
• Follow up on applications
• Handle requests for information
• Track status
• Notify you of approvals

Cost:

• One-time: $500-2,000 per insurance company
• Monthly: $200-500/month for ongoing management
• Percentage: 5-10% of collections (rare)

Pros and Cons

Advantages:

• ✅ Saves 20-40 hours of your time
• ✅ Faster credentialing (they know the process)
• ✅ Less stress and frustration
• ✅ Professional follow-up
• ✅ Higher success rate
• ✅ Worth it for most providers

Disadvantages:

• ❌ Costs $500-2,000 per company
• ❌ Still need to provide documents
• ❌ Less control over process
• ❌ May not be faster for simple cases

When to Use Credentialing Service

Good Candidates:

• Busy providers with limited time
• Providers applying to multiple plans (3+)
• Providers with complex histories
• Group practices
• Providers who value time over money

Can Do It Yourself:

• Solo practitioners with time
• Applying to 1-2 plans only
• Simple, straightforward history
• Budget-conscious providers
• Providers who enjoy paperwork (rare!)

Recommended Services:

• CAQH ProView (free, DIY)
• Credentialing services (Google "medical credentialing service")
• Practice management consultants
• Billing companies (often include credentialing)

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State-Specific Considerations

Medicaid Credentialing

Varies by State:

• Each state has own Medicaid program
• Different application processes
• Different timelines (60-180 days)
• Different reimbursement rates

How to Apply:

• Contact state Medicaid office
• Complete state-specific application
• May use CAQH or separate process
• Submit required documents

Considerations:

• Lower reimbursement rates
• More paperwork
• Serves low-income population
• May be required in some specialties

Medicare Credentialing

Process:

• Apply through PECOS (Provider Enrollment, Chain and Ownership System)
• Separate from CAQH
• 60-90 day timeline
• Required for 65+ population

How to Apply:

1. Go to https://pecos.cms.hhs.gov
2. Create account
3. Complete application
4. Submit documents
5. Wait for approval

Required Documents:

• State license
• DEA (if prescribing)
• Malpractice insurance
• W-9
• EFT information

Considerations:

• Lower reimbursement than commercial
• Required for most primary care
• Large patient population
• Stable payment

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Technology for Credentialing

EHR Requirements

Must Support:

• Multiple insurance payers
• Claim submission
• ERA/EFT processing
• Eligibility verification
• Denial management

ClinikEHR Features:

• Supports all major insurance companies
• Electronic claim submission
• Automatic ERA/EFT posting
• Real-time eligibility checks
• Denial tracking and appeals
• Credentialing status tracking

Clearinghouses

What They Do:

• Route claims to insurance companies
• Check for errors before submission
• Track claim status
• Handle ERA/EFT

Popular Clearinghouses:

• Change Healthcare
• Availity
• Office Ally
• Trizetto

Cost:

• $50-200/month
• Or per-claim fees ($0.50-2.00)
• Often included in EHR

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Related Resources

ClinikEHR Features

• Insurance Billing
• Claims Management
• ERA/EFT Processing
• Credentialing Tracking

Related Guides

• Private Pay vs. Insurance
• How to Start a PMHNP Private Practice
• Best EHRs for Solo & Small Clinics

Official Resources

• CAQH ProView: https://proview.caqh.org
• NPI Registry: https://nppes.cms.hhs.gov
• Medicare PECOS: https://pecos.cms.hhs.gov
• NUCC Taxonomy Codes: https://www.nucc.org

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Frequently Asked Questions

How long does insurance credentialing take? Typically 90-180 days (3-6 months) per insurance company. Some are faster (60 days), others slower (6-12 months). Total time from starting CAQH to receiving first insurance payment is usually 6-7 months.

What is CAQH and do I need it? CAQH is a centralized database that stores your credentialing information. Most major insurance companies use it, so you only enter your information once. Yes, you need it for most insurance credentialing.

How much does credentialing cost? CAQH is free. Insurance applications are usually free. However, you may need malpractice insurance ($1,000-5,000/year) and may want to hire a credentialing service ($500-2,000 per company).

Can I bill insurance while waiting for credentialing? No—you cannot bill insurance until you're officially credentialed with an effective date. You can see patients and provide superbills for out-of-network reimbursement, but you can't bill insurance directly.

Which insurance companies should I apply to first? Start with Blue Cross Blue Shield (largest market share in most states), Medicare (if seeing 65+), and one other major commercial plan (Aetna, UnitedHealthcare, or Cigna). Don't apply to all plans at once.

What happens if my credentialing is denied? Denials are rare but can happen due to disciplinary actions, gaps in training, or incomplete applications. You can appeal the decision, provide additional information, or apply to different insurance companies.

Do I need to recredential? Yes—most insurance companies require re-credentialing every 2-3 years. They'll notify you when it's time. You'll need to update your CAQH profile and submit new documents.

Can I speed up the credentialing process? Yes—complete your CAQH profile 100% before applying, respond to requests within 24 hours, follow up every 2 weeks, and consider hiring a credentialing service. These strategies can save 2-8 weeks.

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Conclusion: Start Early, Stay Organized, Follow Up

Insurance credentialing is tedious but manageable if you approach it systematically. The key is starting early, staying organized, and following up persistently.

Key Takeaways:

• ✅ Start CAQH setup 6 months before opening
• ✅ Get NPI number first (free, immediate)
• ✅ Complete CAQH 100% before applying to insurance
• ✅ Start with 2-3 high-paying plans (BCBS, Medicare, Aetna/UHC)
• ✅ Expect 90-180 days per insurance company
• ✅ Follow up every 2 weeks
• ✅ Respond to requests within 24 hours
• ✅ Consider credentialing service ($500-2,000)

Timeline Summary:

• Month 1: CAQH setup and NPI
• Month 2: Apply to insurance companies
• Months 3-6: Wait and follow up
• Month 7: First insurance payments

Action Steps:

1. Get NPI number today (free, immediate)
2. Create CAQH account this week
3. Gather all required documents
4. Complete CAQH profile (4-6 hours)
5. Research which insurance companies to target
6. Apply to 2-3 companies
7. Follow up every 2 weeks
8. Set up billing in EHR when approved

The 6-7 month wait is frustrating, but proper planning means you can see private pay clients while waiting for credentialing. Don't let credentialing delays stop you from opening your practice.

Start Your Free 30-Day Trial — ClinikEHR supports insurance billing and credentialing tracking.

Questions about credentialing? Contact our team — We help practitioners navigate insurance credentialing every day.

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Disclaimer: Credentialing requirements and timelines vary by insurance company, state, and specialty. This article provides general information for educational purposes. Always verify requirements with specific insurance companies and consult with credentialing specialists for personalized guidance.