Credentialing and Payer Enrollment Services

Maximum Billing, LLC handles credentialing and payer enrollment for medical, behavioral health and dental practices. Applications are tracked to completion, follow-up happens on a schedule, and you get a realistic start date rather than an optimistic one — because scheduling a clinician into sessions that cannot be billed is an expensive way to find out where an application actually stands.

We have specialized in mental health and dental billing since 2018, backed by more than 20 years in insurance billing and revenue management. We are based in Fort Myers, Florida, and work with practices in twelve states, including Florida and Texas.

What We Handle

Initial credentialing applications with commercial payers, Medicare and Medicaid
CAQH ProView setup, maintenance and the attestation that has to be re-signed
Medicare enrollment through PECOS
State Medicaid enrollment, including Florida Medicaid and Texas Medicaid through TMHP
Behavioral health carve-out credentialing, which is separate from the medical carrier
Group and individual enrollment, and linking providers to the group
EFT and ERA enrollment so payments and remittances arrive electronically
Recredentialing and expirable tracking before things lapse
Status follow-up on a schedule, with a straight answer about timelines

What Credentialing Actually Involves

Credentialing is the process by which a payer verifies that a clinician is who they say they are and is qualified to treat their members. Education, training, licensure, work history, malpractice coverage, board certification and sanction checks all get verified at the source rather than taken on trust.

It is administrative work, but it is unforgiving administrative work. A date that does not match between two documents, a gap in work history that is not explained, an old address on a license record — each of these stops an application, and the payer will not necessarily tell you it has stopped. Applications routinely sit for weeks in a state nobody is monitoring.

Credentialing and Contracting Are Not the Same Thing

This is the distinction that causes the most confusion, and the most lost revenue.

Credentialing verifies the clinician. Contracting is the participation agreement — the document that makes you in-network and sets your fee schedule. A clinician can be fully credentialed and still not be in-network, because the contract was never executed or the panel was closed.

Practices discover this when claims come back processed as out-of-network months after they were told credentialing was approved. We track both, and we tell you which one you actually have.

CAQH, PECOS and the Records That Have to Match

Most commercial payers pull credentialing data from CAQH ProView rather than collecting it directly. That makes the CAQH profile the single point of failure for a lot of applications: if it is incomplete, out of date, or the attestation has expired, applications stall across every payer at once.

The attestation has to be re-signed on a recurring cycle — roughly every 120 days — and an expired attestation is one of the most common reasons an application that looked fine is quietly not moving.

Medicare enrollment runs separately through PECOS, and Medicaid runs through the state — Florida through the state Medicaid program, Texas through TMHP before any managed care plan will contract with you. The NPI record, the CAQH profile, the state license and the practice address should all agree. When they do not, the mismatch is usually what is holding things up.

Group practices add another layer: each clinician has to be linked to the group’s enrollment, and Medicare billing through a group requires reassignment in PECOS. Our group practice billing page explains how we handle new hires, departures, and new locations.

Why It Takes So Long

Ninety to a hundred and eighty days is normal for commercial credentialing, and some payers run longer. Very little of that is verification time; most of it is queue time, and queues do not move faster because you need them to.

What you can control is whether the application is clean when it arrives and whether anyone is following it. An application with a missing document does not get rejected on day three — it gets set aside, and unless somebody calls, it can sit until the practice notices months later that nothing has happened.

Effective dates are the part that costs money. Some payers backdate participation to the date they received a complete application. Many do not, and set the effective date when the committee approves. That difference decides whether the services your clinician delivered while waiting are billable at all. It is worth knowing each payer’s rule before you decide when to start scheduling.

EFT and ERA Enrollment

Being credentialed and contracted does not mean you will be paid electronically. EFT — electronic funds transfer — puts payments directly into your bank account instead of mailing a check. ERA — electronic remittance advice, the 835 file — delivers the explanation of payment into your practice management system so it can post automatically.

These are enrolled separately, payer by payer, and they are the step most often skipped. The consequences are unglamorous and constant: paper checks that arrive late or go missing, remittances that have to be keyed in by hand, posting errors introduced by that keying, and payments that cannot be reconciled against claims without someone doing it manually.

Enrollment usually runs through payer portals or a clearinghouse-affiliated service, and each one wants its own forms, its own bank verification, and sometimes a voided check or a bank letter. It is tedious rather than difficult, which is exactly why it gets left undone.

We handle EFT and ERA enrollment as part of getting a practice live, not as an optional extra, because automatic posting is what makes the rest of accounts receivable management work.

Behavioral Health Credentialing

Behavioral health has an extra layer that catches practices out. Many commercial plans delegate behavioral benefits to a separate managed behavioral health organization — Optum, Carelon or Magellan among them — and credentialing with the medical carrier does not credential you with the carve-out. They are separate applications, separate panels and separate contracts.

Behavioral health panels also close more often than medical ones, and a closed panel is not always announced. Sometimes the only way to find out is to apply and be told.

Pre-licensure clinicians add another layer again. Whether an LPC Associate, a supervised LMSW or an LMFT Associate can be credentialed in their own right varies by payer, and where they cannot, services have to be billed under the supervisor with specific documentation. Getting that wrong produces recoupments rather than clean denials. See our behavioral health and psychiatric billing services, or the full detail on our behavioral health credentialing services page.

Dental Credentialing

Dental credentialing runs through the dental plans rather than the medical carriers, and practices billing both medical and dental need both. Children’s Medicaid dental in particular is delivered through statewide dental plans with their own enrollment processes, and in states where that is a primary payer the enrollment has to be in place before any claims can go out. See our dental billing services. For networks, fee schedules, associates and Medicaid dental in detail, see our dental credentialing services.

Medical Credentialing

Physician practices add Medicare enrollment on the CMS-855I and CMS-855B, board certification and hospital privilege checks, and separate rules for nurse practitioners and physician assistants. For Medicare timing, NCQA recredentialing, and group changes, see our medical credentialing services page.

State Medicaid Enrollment Guides

Medicaid enrollment is handled state by state, and every state uses its own portal, documents, and managed care rules. Our step-by-step guides cover the states where we see the most questions:

Recredentialing and Expirables

Credentialing is not finished when it is approved. Most payers recredential on roughly a three-year cycle, and the documents behind it expire on their own schedules — state license, DEA registration, malpractice coverage, board certification.

A lapsed expirable can suspend participation without much warning, and claims submitted during a lapse get denied for a reason that looks like a coding problem and is not. We track these dates and start the renewal before the deadline, rather than reacting to a denial.

Frequently Asked Questions

How long does credentialing take?

Ninety to a hundred and eighty days is normal for commercial payers, and some run longer. Medicare and Medicaid vary by state. We will give you a realistic estimate per payer rather than a single reassuring number.

Can we see patients while credentialing is pending?

You can, but whether those services are billable depends on the payer’s effective date rule. Some backdate to a complete application, many do not. That is the question to settle before you start scheduling, not after.

Are credentialing and being in-network the same thing?

No. Credentialing verifies the clinician; contracting makes you in-network and sets your rates. It is possible to be credentialed and still out of network, and practices usually discover it from the remittance.

Do you handle behavioral health carve-outs?

Yes, and they need separate applications. Being credentialed with a medical carrier does not credential you with the behavioral health organization that actually manages the benefit.

What is EFT and ERA enrollment, and do we need it?

EFT deposits payments directly into your account; ERA delivers the electronic remittance so payments post automatically. You are not required to have either, but without them you are reconciling paper by hand, which is slower and produces posting errors.

Will you track our recredentialing dates?

Yes, along with license, DEA, malpractice and board certification expiration dates. Renewals get started before the deadline rather than after a denial.

If you have a clinician waiting on a panel, or you are not certain whether you are credentialed or actually contracted, those are answerable questions. Contact Maximum Billing, LLC or call 800-820-0364. See also our medical billing services for Florida practices and our guides to understanding credentialing and mental health credentialing.

Credentialing and Payer Enrollment