A physician, nurse practitioner, or physician assistant can be fully licensed and board certified and still be unable to bill a patient’s plan. Medical credentialing and payer enrollment are what turn a new clinician, a new location, or a new practice into one that insurers will pay. Maximum Billing handles medical credentialing for physician practices and specialty groups in twelve states, including Florida and Texas, from Medicare enrollment to commercial contracts and recredentialing.
Schedule a consultation or call 800-820-0364.
What Our Medical Credentialing Includes
- Medicare enrollment and revalidation through PECOS for individual clinicians and groups.
- State Medicaid enrollment and credentialing with Medicaid managed care plans.
- Commercial and Medicare Advantage applications, with scheduled follow-up until approval.
- CAQH ProView setup, document management, and re-attestation.
- NPI, taxonomy, and practice location review so every record matches.
- Contract and fee schedule review before signing.
- Adding new physicians, nurse practitioners, and physician assistants to existing contracts.
- New locations, tax ID changes, and ownership changes.
- EFT and ERA enrollment with each payer.
- Expiration tracking for licenses, DEA registrations, board certifications, malpractice coverage, and CLIA certificates.
Medicare Enrollment Through PECOS
Individual physicians and non-physician practitioners enroll using the CMS-855I, and groups and clinics use the CMS-855B. Reassignment of benefits, which lets a group bill for a clinician’s services, used to require a separate CMS-855R. CMS discontinued that form and now captures reassignment on the CMS-855I. Most applications are submitted electronically through PECOS.
Timing matters. Once enrollment is approved, physicians and non-physician practitioners can generally bill retroactively for services provided up to 30 days before the date their application was filed, or up to 90 days in certain emergencies. Services before that window cannot be billed to Medicare, so we file as soon as a new clinician’s start date is set. After enrollment, most providers must revalidate every five years.
Nurse Practitioners and Physician Assistants
NPs and PAs are credentialed in their own right with Medicare and most commercial plans. Medicare generally pays their services at 85% of the physician fee schedule when billed under their own NPI. Billing their services “incident to” a physician at the full rate is allowed only when Medicare’s specific supervision and plan-of-care requirements are met, and payers and auditors review it closely. Commercial plans have their own rules for NPs and PAs, and some require a collaborating or supervising physician on the application. We set up each clinician’s enrollment and billing under the rules that actually apply.
What Payers Ask For
Medical credentialing applications typically require:
- State medical or nursing license for every state of practice
- DEA registration and any state controlled substance registration for prescribers
- Board certification or eligibility, with dates
- Education, training, and a complete work history, with gaps explained
- Professional liability insurance certificate and claims history
- Hospital privileges or an admitting arrangement, when the payer requires one
- CLIA certificate for practices that perform in-office lab testing
- W-9, tax ID documentation, and practice location details
Payers verify much of this directly with the issuing sources, which is why a small discrepancy, such as an unexplained gap or an expired certificate, can stop an application.
Primary Source Verification and Recredentialing
Health plans that follow NCQA credentialing standards verify licenses, education, board certification, and sanction history with the original sources, and they recredential each clinician at least every 36 months. CAQH profiles must be re-attested roughly every 120 days. When any of these lapse, payments can be held or the clinician can be removed from the network. We keep a calendar for every clinician and respond to recredentialing requests before their deadlines.
Medicaid and Managed Care Plans
Federal rules require clinicians in Medicaid managed care networks to be enrolled with the state Medicaid program, so Medicaid credentialing is a two-step process: state enrollment first, then each managed care plan. Timelines, forms, and revalidation schedules differ by state. See our state medical billing pages for Florida, Texas, and New Jersey for each state’s Medicaid details. Our state Medicaid provider enrollment guides walk through each program step by step: Colorado, Connecticut, Florida, Georgia, Illinois, Missouri, New Jersey, New York, and Texas.
Groups, New Locations, and Ownership Changes
Adding a location, changing a tax ID, or buying a practice all require payer notifications and, often, new applications. Payments can be interrupted if a payer’s records do not match the tax ID on the claim. Larger groups may qualify for delegated credentialing, where a payer allows the group to credential its own clinicians under an agreement, which can shorten onboarding. We plan these changes with you so the effective dates line up and claims keep paying.
Common Reasons Medical Credentialing Stalls
- An expired CAQH attestation or missing documents on the profile.
- Names, addresses, or taxonomy codes that do not match across NPPES, CAQH, PECOS, and the application.
- Unexplained gaps in work history.
- Missing hospital privileges or admitting arrangements required by the payer.
- A closed network for the specialty in that area.
- Applications that no one follows up on after submission.
Commercial credentialing commonly takes 90 to 180 days, and most commercial plans do not pay retroactively for services before the contract’s effective date. Starting early and following up on a schedule is the most reliable way to shorten the wait.
Frequently Asked Questions
When should we start credentialing a new physician?
As soon as the start date and practice location are known, often three to six months ahead. Medicare can be filed closer to the start date because of its 30-day retroactive billing window, but commercial plans usually cannot.
Do you credential nurse practitioners and physician assistants?
Yes, with Medicare, Medicaid, and commercial plans, including any supervising or collaborating physician requirements.
Can you handle revalidation and recredentialing for our existing providers?
Yes. We track every expiration and respond to revalidation and recredentialing requests before their deadlines.
Do you also handle medical billing?
Yes. See our credentialing and payer enrollment overview and our state medical billing pages linked above.
Credentialing That Keeps Your Schedule Full
If you are adding clinicians, opening a location, or catching up on revalidations, we can manage the process from start to finish. Contact us or call 800-820-0364.