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Credentialing readiness checklist

Most insurer applications stall for the same few reasons: an unattested CAQH profile, details that don't match across forms, or one missing document. Get these ready before you apply and every application goes faster.

Keep sensitive details out of email. Social Security numbers, dates of birth and bank details should never be sent by email, to us or anyone else. Use a secure, shared password-manager vault or the insurer's own portal.

1. Identity and numbers

For every clinician, and for the practice.

• Individual NPI (Type 1) for each clinicianLook it up in the NPPES registry and confirm the name matches the license exactly.
• Group NPI (Type 2), if you bill as a practiceNeeded when claims go out under the business rather than the individual.
• NPPES record is currentPractice location, mailing address, phone and primary taxonomy code. The taxonomy should match the license type you will list on every application.
• EIN confirmation from the IRS and a signed W-9The legal business name on the IRS letter must match the name on applications and contracts, character for character.
• Business formation documentsArticles of organization or incorporation and the state registration (in Virginia, the SCC record).

2. Licenses and coverage

• Active state license for each clinicianCheck the expiration date. A license that expires during review can restart an application.
• DEA registration, if the clinician prescribes controlled substancesRegistered to the state where they practice.
• Board certification, if applicableCertificate or verification printout with the expiration date.
• Current malpractice certificate (face sheet)Shows the clinician's name, policy dates and limits. Check each insurer's required limits; many ask for $1M per claim and $3M aggregate.
• Hospital privileges or a written admitting arrangement, if the insurer requires oneCommon for physicians and some NPs; usually not required for outpatient therapists.

3. History and documents

• Current CV in month/year formatEvery job and training program with start and end month and year.
• Explanations for gaps in work historyCredentialing reviewers commonly ask about gaps of six months or more in the last five years. A one-line written explanation for each avoids a back-and-forth.
• Diplomas and training certificatesDegree, residency or fellowship, and any required supervision or certification records.
• Malpractice claims history, if anyA short written summary of each claim and its outcome.
• Professional references, if requestedSome insurers and hospitals ask for two or three peer references with current contact details.

4. CAQH profile (now operated as DataSpring)

Most commercial insurers pull your information from here instead of a paper application.

• Profile is complete, with every section filled inPractice locations, hours, specialties, education, work history and liability coverage.
• Supporting documents uploaded and not expiredLicense, DEA (if any), malpractice certificate, board certificate, CV.
• Insurers are authorized to view the profileEither "all plans" or the specific plans you're applying to. A profile insurers can't see is the same as no profile.
• Profile is attestedThe clinician confirms the information is accurate. Attestation must be repeated about every 120 days, so set a reminder at day 100.
• Details match NPPES and the licenseName, addresses and taxonomy. Mismatches are a frequent reason for a returned application.

5. Medicare (PECOS)

• CMS Identity & Access (I&A) account for each clinician and the practiceThe login used for PECOS. The clinician creates their own; nobody should share passwords.
• Owners and managing employees listedMedicare asks for anyone with ownership or managing control of the practice.
• Reassignment of benefits, if clinicians bill under the groupEach clinician reassigns payments to the practice.
• Electronic funds transfer (EFT) set upMedicare pays by EFT. Have a bank letter or voided check ready, and share it securely, never by email.
• Revalidation date on your calendarMost providers revalidate every five years. CMS publishes due dates on its revalidation list in advance.

6. Virginia Medicaid and Cardinal Care

Only if you practice in Virginia.

• Enroll with Virginia Medicaid (DMAS) firstThrough the DMAS provider enrollment portal. The managed care plans generally expect Medicaid enrollment to be in place.
• Then apply to each Cardinal Care managed care plan you wantEach plan credentials and contracts separately. Some networks close to certain specialties for a time; ask to be waitlisted when that happens.

7. Before you start seeing patients under a plan

• A signed contract or welcome letter with your effective dateApproval for credentialing and a signed contract are separate steps with some insurers. Confirm both.
• Your fee scheduleAsk for it before signing, so you know what each service pays.
• Your billing system has each payer ID and the effective dateClaims sent before the effective date are usually denied.

How long it takes

Insurers decide their own timelines, and they vary. Published estimates from the insurers themselves are a reasonable starting point:

Insurer	Their published estimate
UnitedHealthcare	Up to 45 calendar days or more
Anthem	Typically about 45 days
Cigna / Evernorth Behavioral	Up to 90 calendar days

Many practices plan on 60 to 120 days per insurer and apply about four months before they want to see patients under that plan. Nobody can promise an approval or a date; the insurer decides both.

This checklist is general information, not legal advice. Requirements vary by insurer, state and license type; always follow the insurer's current instructions. CAQH, DataSpring, PECOS and insurer names belong to their owners and are used only to describe what each step involves.