Behavioral health credentialing checklist, by payer and provider type

At a minimum you will need a valid state license, your NPI (both Type 1 individual and, if applicable, Type 2 organizational), a completed CAQH ProView profile, proof of professional liability (malpractice) insurance, your CV or work history covering the past five to ten years, copies of any specialty board certifications, and your DEA registration if you prescribe controlled substances. Most payers also require a W-9, a completed provider enrollment application specific to that payer, and attestations about prior malpractice claims and disciplinary actions. Having all documents current and organized before you start your first application dramatically reduces back-and-forth with payer credentialing departments.

CAQH ProView is a centralized database that most commercial payers use to collect and verify provider credentials. Instead of submitting the same documents separately to Aetna, BCBS, Cigna, and United, you complete your profile once in CAQH and authorize each payer to access it. Payers then pull your information directly during credentialing and re-credentialing. The catch is that CAQH requires regular attestation, typically every 120 days, confirming your information is current. An outdated CAQH profile is one of the most common reasons credentialing is delayed, because payers will not process applications tied to an expired attestation.

Medicare enrollment through PECOS typically takes 60 to 90 days from the date of a complete application, though processing times vary by Medicare Administrative Contractor and application volume. Individual provider enrollments tend to move faster than group enrollments. If your application is returned for missing information, the clock effectively resets. One important option while you wait: Medicare allows a 30-day retroactive billing period if you apply within 30 days of your enrollment effective date, so timing your application relative to your start date matters.

It depends on the payer. Most commercial payers do not allow retroactive billing, which means you cannot bill insurance for services rendered before your credentialing effective date. However, you can see patients on a self-pay or fee-for-service basis while you wait. Some payers offer a provisional credentialing option, and Medicare allows limited retroactive billing as noted above. Medicaid rules vary significantly by state. The safest approach is to confirm each payer’s policy in writing before scheduling insured patients and to collect payment directly from any patients you see during the pending period.

Credentialing is the process by which a payer verifies your qualifications: your license, education, training, malpractice history, and practice information. Contracting is the separate process of negotiating and executing the legal agreement that sets your reimbursement rates and terms of participation. You must complete credentialing before contracting can happen, and contracting must be finalized before you can bill as an in-network provider. Some payers handle both steps simultaneously; others keep them sequential with different departments involved. This is why the overall timeline from first application to first in-network claim can often reach four to six months.

Most payers require re-credentialing every two to three years. In between, you are responsible for notifying payers of material changes: a new address or practice location, a lapse or change in malpractice coverage, any disciplinary action or license restriction, and changes to your DEA registration if you prescribe. You also need to keep your CAQH attestation current every 120 days. Letting any of these lapse can trigger a credentialing hold that prevents claims from processing. Building calendar reminders for expiration dates on your license, DEA, malpractice policy, and CAQH attestation is the simplest way to stay on top of it.