Credentialing and Enrollment
US Medical Billing gets your providers credentialed and enrolled with the payers you bill — building and maintaining CAQH, submitting Medicare, Medicaid, and commercial applications, tracking effective dates, and keeping enrollments active through revalidation.
- CAQH, Medicare, Medicaid, and commercial enrollment
- Effective dates confirmed before billing
- Revalidation and maintenance tracked
- Group rosters kept current
What credentialing and enrollment does
Credentialing and enrollment are what make a provider billable. Credentialing is the verification of a provider's qualifications — license, education, training, board certification, work history, and malpractice coverage. Enrollment is the separate step of registering that verified provider with a specific payer so claims can be submitted and paid under a contract.
The two are related but distinct, and both have to be complete before a payer will reimburse. A provider can be fully licensed and still unable to bill a plan until enrollment is approved and an effective date is assigned — which is why claims submitted too early are so often denied.
US Medical Billing manages this end to end: we build and maintain CAQH, prepare and submit applications to Medicare through PECOS, to state Medicaid programs, and to commercial payers, then follow each one to approval, confirm effective dates, and keep enrollments active through revalidation and roster updates.
Who it's for
Credentialing and enrollment come up at specific moments in a practice's life. These are the situations this service fits.
New practices and providers
A new group or a newly licensed provider that needs to be enrolled with payers before it can bill for the care it delivers.
Providers joining a group
A clinician moving to your practice who needs to be enrolled under your group and, where applicable, have their Medicare benefits reassigned to it.
Practices adding payers or locations
An established group expanding into new plans, a new state Medicaid program, or a new service location that has to be added to existing enrollments.
What's included
Enrollment spans several payer systems and does not end at approval. These are the core parts of the service.
CAQH ProView setup & attestation
Build or take over the CAQH profile that commercial payers pull from, keep documents current, and re-attest on schedule so the profile stays usable.
Medicare enrollment (PECOS)
Prepare and submit individual, group, and reassignment applications through PECOS and follow them to an approved effective date.
Medicaid enrollment
Enroll providers with the applicable state Medicaid program, including managed-care plan enrollment where the state requires it.
Commercial payer applications
Complete and submit applications to commercial and managed-care payers, including participation requests and contract packets.
Revalidation & maintenance
Track revalidation cycles, license and document expirations, and re-attestation dates so an active enrollment is not lost to a missed deadline.
Roster & group management
Add and terminate providers on group rosters and keep payer records aligned with your current provider list and locations.
Effective date & status tracking
Record confirmation numbers, provider IDs, and effective dates, and maintain a live view of where every application stands.
How enrollment works
Enrollment moves an application from a provider's documents to an active, billable payer record. Each stage is where a submission is either kept clean or sent back to the start.
Data collection & documents
Gather the provider's identifiers and supporting documents — NPI, licenses, DEA, board certifications, work and education history, and the malpractice certificate of insurance — and check them for consistency.
Inputs and outputs
Enrollment is document-driven. These are the concrete artifacts that go in and what comes back out.
What you provide
- Provider NPIs (Type 1) and the group NPI (Type 2)
- State license(s) and DEA registration
- Board certifications, plus education and work history
- Malpractice certificate of insurance
- Practice details, W-9, and service locations
What you get back
- A built and attested CAQH profile
- Submitted payer applications with confirmation numbers
- Assigned provider IDs and confirmed effective dates
- A live enrollment status record by provider and payer
- A revalidation and expirables calendar
Responsibilities and boundaries
An honest split of what the service handles, what is shared, and what stays with the provider and practice.
We handle
- Preparing, submitting, and following up on applications across CAQH, PECOS, Medicaid, and commercial payers
- Tracking effective dates, provider IDs, and confirmation numbers
- Monitoring revalidation cycles, document expirations, and re-attestation deadlines
- Maintaining group rosters and location records with payers
Shared
- Assembling accurate, current provider data and documents
- Signatures and attestations that only the provider can legally give
- Deciding which payers and plans to pursue
You keep
- The provider's actual licensure, board certification, and clinical qualifications
- Malpractice coverage decisions and the underlying policy
- Whether to accept a payer's contract and its reimbursement rates
Common process failures
Most enrollment problems trace back to a small set of failure modes. Each is how it arises and how we prevent or work it.
Billing before the effective date
Claims for services rendered before the assigned effective date are generally not payable under the payer contract, and not every payer backdates. We confirm the effective date before billing begins and flag any gap between the start of care and the date the provider is billable.
Lapsed CAQH attestation
Commercial payers pull from CAQH, and a profile that is not re-attested on its recurring cycle — or that carries an expired license or insurance document — can stall or unwind an enrollment. We track attestation dates and document expirations and act before they lapse.
Missed revalidation
Enrollments are not permanent; Medicare, for example, requires periodic revalidation, and a missed due date can deactivate a provider and interrupt payment. We monitor revalidation cycles and submit ahead of the deadline rather than after a deactivation.
Incomplete or inconsistent applications
Gaps in work history, mismatched names, addresses, or NPIs, and missing documents cause payers to return an application and restart its clock. We verify data for internal consistency across payers before anything is submitted.
Reporting and visibility
You keep a clear view of every enrollment without chasing status yourself. What you can see:
Enrollment status by provider and payer
A live view of where each application stands — submitted, in process, additional information requested, or approved.
Effective dates and payer IDs
A record of confirmed effective dates, assigned provider IDs, and submission confirmation numbers for each approved enrollment.
Expirables and revalidation calendar
Upcoming license and document expirations, CAQH re-attestation dates, and revalidation deadlines, so nothing active is lost to a missed date.
What to expect
How we approach the work — these describe the service, not guaranteed outcomes or timelines.
Payers control the timeline
We manage each application end to end, but every payer sets its own processing time — some clear in weeks, others take months. We set that expectation honestly and keep applications moving rather than waiting on them.
Accuracy before submission
Documents and identifiers are checked for consistency before an application goes out, because a returned application restarts the payer's clock.
Enrollment is maintained, not filed and forgotten
Revalidation, re-attestation, and roster changes are tracked so a completed enrollment stays active instead of lapsing quietly.
One tracked pipeline
Every provider and payer is managed in a single, connected process with a clear status, rather than as scattered one-off applications.
Related & connected
Enrollment is the front end of getting paid. These are the services and articles that connect to it.
Related services
From the Knowledge Base
- Credentialing vs. enrollmentWhy the two are distinct steps and why both are required before you can bill.
- Effective datesWhat an effective date is, how it is assigned, and why it decides which claims get paid.
- Enrollment pathwaysHow CAQH, Medicare, Medicaid, and commercial enrollment differ in practice.
- Enrollment maintenanceRevalidation, re-attestation, and roster updates that keep an enrollment active.
Frequently asked questions
What is the difference between credentialing and enrollment?
Credentialing is the verification of a provider's qualifications — license, education, training, board certification, work history, and malpractice coverage. Enrollment is registering that verified provider with a specific payer so claims can be submitted and paid under a contract. A provider can be credentialed and still be unable to bill a plan until enrollment with that plan is approved. Both steps are required before reimbursement.
How long does payer enrollment take?
The timeline is set by each payer, not by us, and it varies widely by payer, provider type, and how complete the application is. Some enrollments clear in a few weeks and others take several months. We keep applications moving, respond to requests for additional information quickly, and give you a realistic expectation for each payer rather than a blanket promise.
Can a provider bill before enrollment is complete?
Generally no. Claims for services rendered before the assigned effective date are usually not payable under the payer contract. Some payers backdate the effective date to when they received the application, but many do not, which can leave a gap where early services are not billable. We confirm the effective date for each payer before billing starts and flag any gap so it is a known decision rather than a surprise denial.
What is CAQH and is it required?
CAQH ProView is a centralized profile that many commercial payers use to access a provider's credentialing information instead of collecting it separately. If you bill commercial plans, an accurate, attested CAQH profile is typically required, and it has to be re-attested on a recurring cycle with current documents to stay usable. We build or take over the profile and keep it attested and up to date.
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