In today’s healthcare environment, credentialing is more than just a regulatory requirement, it’s a critical process that protects patients, enhances a provider’s professional standing, and ensures insurance reimbursements. Whether you’re a new provider, a seasoned professional joining a new group or a facility expanding your network participation, understanding the credentialing process can save time, reduce stress, and prevent costly delays.
At Eyecare Billing Associates, we specialize in managing the entire credentialing process so providers can focus on what they do best caring for patients. In this guide, we break down the credentialing journey step-by-step from application to approval.
What Is Credentialing?
Credentialing is the process of verifying a healthcare provider’s qualifications, including education, training, licensure, certifications, and work history. It’s required by hospitals, medical groups, and insurance companies before a provider can treat patients or receive reimbursements.
Credentialing ensures that a provider:
- Has the proper education and training
- Holds an active, unrestricted license
- Maintains board certification (if applicable)
- Has no significant malpractice or disciplinary actions
- Is in good standing with state and federal authorities
Credentialing also plays a key role in payer enrollment, which allows providers to be reimbursed for services rendered under insurance plans.
Step 1: Gathering Information
The first phase of credentialing is collecting all the necessary documentation and details. This is often the most time-consuming part of the process, and many delays occur if information is missing or inaccurate.
Typical documents and information required include:
- Medical license(s)
- DEA certificate
- Board certifications
- Malpractice insurance (with adequate limits)
- Education and training records
- Work history (with explanations for gaps)
- Hospital privileges (if applicable)
- State and federal IDs (e.g., NPI number)
- References or letters of recommendation
At Eyecare Billing Associates, we streamline this step by sending providers a tailored checklist and digital intake forms that reduce paperwork and improve accuracy.
Step 2: CAQH Profile Setup and Attestation
Most commercial payers require providers to maintain a current profile with the Council for Affordable Quality Healthcare (CAQH). This centralized database stores provider credentials and allows payers to access verified information quickly.
Providers must:
- Create a CAQH account (or update an existing one)
- Upload all credentialing documents
- Attest to the accuracy of the data every 120 days
Eyecare Billing Associates handles CAQH setup and re-attestation on behalf of our clients to ensure it stays up-to-date because even one missed attestation can stall your applications.
Step 3: Submitting Applications to Payers and Facilities
Once your credentials are gathered and verified, we begin submitting applications to health plans, hospitals, and other entities where you’re seeking privileges or in-network status.
Each payer has its own application format and unique requirements. Applications must be filled out meticulously and include:
- Personal and professional history
- Liability claims history
- Practice details (locations, tax ID, group NPI, etc.)
- Signed agreements or contracts
We track and manage all application submissions to ensure nothing is lost or delayed. Even a single missed field can lead to rejections or requests for resubmission.
Step 4: Primary Source Verification
After receiving the application, the payer or facility begins primary source verification. This means they confirm all credentials directly with the issuing organizations. For example:
- Medical school degrees are verified by the school
- Licenses are checked with state boards
- Certifications are validated with specialty boards
- Background checks may be conducted
This phase can take several weeks, especially if the verifying bodies are slow to respond. At Eyecare Billing Associates, we maintain active communication with these entities and follow up regularly to keep the process moving.
Step 5: Credentialing Committee Review
Once verification is complete, the application is forwarded to a credentialing committee, which is a panel of medical professionals and administrators who review all findings.
They assess:
- Qualifications and experience
- Any red flags in the background or malpractice history
- Overall fit for the network or facility
If the committee identifies issues (like license restrictions or recent gaps in practice), they may request additional documentation or clarification. In rare cases, applications may be denied or deferred.
Eyecare Billing Associates helps prepare and present clarifying statements, letters of explanation, and appeals, when necessary, to improve approval outcomes.
Step 6: Approval and Enrollment
Once approved, the provider receives:
- Network participation status with the payer
- Facility privileges (if applicable)
- Effective date for billing and reimbursement
Note: Approval doesn’t always mean you can start billing immediately. Some payers require contract execution or Welcome Letters before claims can be submitted.
We carefully track and confirm all final approvals to make sure your billing team knows exactly when you’re eligible to begin seeing patients under each plan.
How Long Does Credentialing Take?
Credentialing can take anywhere from 60 to 180 days, depending on:
- The number of payers/facilities involved
- How quickly documents are submitted
- Responsiveness of licensing boards and references
- Payer-specific timelines
We speed up the process by keeping documentation organized, following up frequently, and staying ahead of potential roadblocks.
Common Credentialing Pitfalls
Providers and practices often face delays because of:
- Incomplete or inconsistent information
- Outdated CAQH profiles
- Missed document deadlines
- Lack of follow-up with payers
- Failing to track credentialing expiration dates
That’s why outsourcing credentialing to a dedicated team like ours saves time, reduces administrative burdens, and protects your revenue stream.
Why Credentialing Works?
Credentialing isn’t just a one-time task it’s an ongoing process. From initial credentialing to recredentialing, payer updates, and maintenance of hospital privileges, the demands never stop.
Eyecare Billing Associates offers:
Full-service credentialing and payer enrollment
Dedicated credentialing specialists
CAQH and NPPES management
Real-time status updates
Ongoing recredentialing support
Tailored packages for individual providers, group practices, and large facilities
We’re passionate about getting you credentialed quickly, accurately, and with the least disruption to your business.
Final Thoughts
Credentialing may be behind the scenes, but it has very real impacts on your practice’s ability to serve patients and receive timely reimbursement. By understanding each step of the process and partnering with professionals who specialize in it, you can avoid frustrating delays and focus on delivering care.
At Eyecare Billing Associates, we’re proud to take credentialing off your plate so you can focus on what truly matters: your patients.
Need help with your credentialing process? Contact us today to get started.