Physician Credentialing Services for MDs and DOs
CAQH, Medicare, Medicaid and commercial payer enrollment for physicians, with weekly follow-up until each payer confirms an effective date in writing. A flat $250 per payer application, per physician.
Physician credentialing services get an MD or DO verified by and enrolled with each insurance payer: the CAQH profile, Medicare through PECOS, the state Medicaid program and every commercial plan the practice chooses, followed up weekly until each payer issues a written effective date. ClaimCarePro does this for a flat $250 per payer application, per physician.
This page is for physicians and the people who run their practices: a solo doctor opening an office, a physician joining a group, a group adding several doctors at once, and the hospitalist or rounding physician who needs payer ID numbers but no contract. For how credentialing works for every provider type, including the difference between credentialing, enrollment and contracting, see our provider credentialing services page and what provider credentialing is.
Updated 2026-10-23. Reviewed by Jacob Greenberg, ClaimCarePro.
What our physician credentialing service covers
Every piece a physician needs to bill in network, and what you hold when each one is finished.
| Piece | What we do | Form or portal | What you have when it ends |
|---|---|---|---|
| CAQH profile | Build or clean up the profile, upload current documents, authorize each plan, attest, and calendar re-attestation | CAQH Provider Data Portal (now DataSpring) | A profile every commercial plan can read |
| Medicare | Individual enrollment for the physician, the group enrollment if the practice is new, and the reassignment linking them | PECOS or paper CMS-855I (individual and reassignment) and CMS-855B (group) | A PTAN and a written effective date |
| Medicaid | Enrollment in the state Medicaid program, plus registration with the Medicaid managed-care plans where the state requires it | The state Medicaid enrollment portal | A Medicaid provider ID |
| Commercial payers | One complete application per payer, per physician, for each plan you choose | Each payer’s own application or “join our network” request, usually read from CAQH | Participation, or a roster add to a group already in network |
| Follow-up | Every payer, every week: representative, date, reference number and next step logged | Phone and payer portals | A status log you can read at any time |
| Re-credentialing and revalidation | Payer cycles, Medicare and Medicaid revalidation, CAQH re-attestation and expiring documents tracked on one calendar | CAQH, PECOS, state portal, each plan | No lapse in network status |
Medicare does not read CAQH; it enrolls physicians through PECOS, explained on what PECOS is. CMS folded the old CMS-855R reassignment form into the CMS-855I (CMS consolidated CMS-855I bulletin), so one individual application now carries both the physician's enrollment and the reassignment to the group. Which payers to file with, and in what order, is listed in our payer-by-payer credentialing guides.
Credentialing for physicians: four situations, four different jobs
The applications look alike. What has to happen first, and what can go wrong, does not.
A solo physician opening a new practice
The practice has to exist in each payer's system before the physician can be linked to it: the group NPI, tax ID, service location and bank details come first, then the physician's individual enrollment and reassignment. The opening date drives the order. This is what the new-practice bundle is for: CAQH, Medicare, Medicaid and six commercial payers for one physician, $1,750.
A physician joining an existing group
The group is already in network, so only the physician's file has to clear. A physician who has enrolled before usually has a CAQH profile and an existing Medicare enrollment; we update and re-link those rather than start over. Tell us which payers the physician is already in, under which tax IDs.
A group adding several physicians at once
Same group, same payers, several files. The first physician is $1,750 on the bundle and each additional physician on the same group and payers is $1,400. We run the files in parallel and give you one status log for all of them.
Hospitalists and rounding physicians who need their own payer IDs
A physician who rounds at hospitals is often billed by the hospital's physician group, under the group's tax ID. The hospital and its group are already in network. The physician is not, until each payer enrolls him or her individually and links the enrollment to that group. That is enrollment, not contracting: for Medicare a CMS-855I with a reassignment of benefits, for Medicaid the state enrollment plus any group linkage the state requires, and for commercial plans a roster add under the group's existing agreement. A physician who rounds for more than one group needs a link to each.
How to do physician credentialing, step by step
The order that keeps every payer clock moving. Most delays happen in steps one and two.
- Collect and cross-check the file. License, DEA registration, board certification, malpractice certificate and claims history, medical school, residency and fellowship, CV and hospital affiliations, compared line by line before anything is filed.
- Set up or clean up CAQH, authorize each plan and attest. See what CAQH is.
- File Medicare: the CMS-855I in PECOS with the reassignment, and the group's CMS-855B if the group is new. Medicare charges no application fee to physicians or physician groups; the fee in 42 CFR 424.514 applies to institutional providers, which 42 CFR 424.502 defines to exclude physician organizations.
- File Medicaid. Federal rules require a state Medicaid program to enroll every physician who orders or refers for its members, not only those who bill (42 CFR 455.410(b)).
- Submit one complete application per commercial payer.
- Follow up every week with every payer and log the representative, date, reference number and next step. Requests for more information are answered the day they arrive.
- Get the effective date in writing for each payer before billing under it as in network.
The Medicare date rule worth knowing. A physician's Medicare effective date is the later of the date an application that was later approved was filed, or the date the physician first furnished services at the new practice location (42 CFR 424.520(d)). If circumstances prevented enrolling in advance, the physician may bill retrospectively for up to 30 days before that date (42 CFR 424.521(a)). Filing late costs visits that can never be billed, which is why Medicare goes in as soon as the file is complete. Commercial plans publish their own clocks; the ones payers publish are in the timeline table on our credentialing services page.
How much does physician credentialing cost?
Flat, published fees. The same for an MD or a DO, a solo office or a group.
Physician credentialing at ClaimCarePro costs $250 per payer application per physician, $250 for CAQH setup or cleanup, $250 per payer for re-credentialing, and $99 per physician per year for maintenance. The physician credentialing companies we reviewed for this page either asked for a call before quoting or published only wide ranges. Ours is the whole list.
| Service | Price |
|---|---|
CAQH profile setup or cleanup | $250 per provider, one-time |
Payer enrollment — commercial, Medicare, or Medicaid Aetna, BCBS Florida, Cigna, UnitedHealthcare, Humana, Medicare, Medicaid, and more | $250 per payer, per provider |
Re-credentialing / revalidation Same rate as initial enrollment | $250 per payer, per provider |
New-practice bundle CAQH + Medicare + Medicaid + 6 commercial payers · list $2,250 — saves $500 | $1,750 per provider |
Additional provider, same group & payers | $1,400 per provider |
Credentialing maintenance CAQH re-attestation, expirables monitoring, demographic and TIN updates — revalidation billed separately | $99 per provider / year, billed annually |
Every enrollment fee includes application preparation and submission, weekly payer follow-up until approval, and written confirmation of your effective date. Payer- or state-imposed application fees are passed through at cost.
Annual maintenance covers CAQH re-attestation (the 120-day clock), expirables monitoring, and demographic and TIN updates with each payer. Revalidation and re-credentialing applications are billed separately at the standard enrollment rate.
Timeline: it depends on the payer, and only some publish a number (Florida Medicaid 60 days or less from a complete file; UnitedHealthcare generally up to 14 calendar days; Florida Blue 30 business days after committee). Every clock starts only when the file is complete. We follow up weekly until you’re in-network — you’ll never wonder where an application stands.
Worked example: one physician, six payers
A newly hired physician needs Medicare, Medicaid and four commercial plans, and has no CAQH profile yet.
| Option | Arithmetic | Total |
|---|---|---|
| Per application | 6 payers × $250 = $1,500, plus CAQH setup $250 | $1,750 |
| New-practice bundle | CAQH + Medicare + Medicaid + up to 6 commercial payers, one physician | $1,750, with room for 2 more commercial plans |
| A second physician, same group and payers | Bundle rate for each additional physician | $1,400 |
| Maintenance (optional) | 1 physician × $99 per year | $99 a year |
At six payers the two options cost the same, so the bundle is the better buy whenever the physician may join more commercial plans in the first year. Payer- or state-imposed application fees, where a payer charges one, are passed through at cost. Maintenance covers CAQH re-attestation, expirables monitoring and address and tax-ID updates; when a payer recredentials or Medicare revalidates, that application is $250.
What we need from the physician
A short list, collected once: state license and DEA registration, board certification details or residency completion, malpractice certificate of insurance and claims history, CV with month-and-year dates, hospital affiliations, individual NPI, CAQH login if one exists, and Medicare enrollment details if the physician has billed Medicare before. From the practice: group NPI, tax ID with the W-9, service locations and the payer list. The full intake list, with why each item is on it, is on what we need to start your credentialing.
Why physician credentialing applications stall
In our casework, credentialing stalls most often on bad data from the providers, not on the payers.
| Problem | What it looks like |
|---|---|
| Practice location mismatch | The CAQH profile, the application and the state license record list different addresses or suites, so the payer sees two locations. |
| Work history gaps | NCQA standards review at least five years of work history and require gaps of six months or more to be explained, per an NCQA Q&A published by the AMA. Residency, fellowship and locum dates that do not match the CV come back as questions. |
| Lapsed or old documents | A renewed license, DEA registration or malpractice certificate never re-uploaded, or a board certification shown with its old expiration date. |
| NPI and tax ID mix-ups | The physician’s individual (Type 1) NPI and the group’s (Type 2) NPI swapped, or a tax ID and legal name that read differently on the W-9 and the application. |
| Reassignment missing | The physician is enrolled but never linked to the group that bills, so claims under the group reject even though both are in Medicare. |
| Hospital affiliation details | Privileges, admitting arrangements or hospital names that differ between the CAQH profile and the hospital’s own records. |
Each of these becomes a question from the payer and a file that waits for the answer. The fix is the cross-check in step one: CV, CAQH, license record, W-9 and application read side by side before anything is filed. Work history standards are from an NCQA standards Q&A the AMA published in 2022.
MD vs DO credentialing: is there a difference?
No, not in payer terms. Medicare defines a physician as “a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State” (Social Security Act §1861(r), 42 U.S.C. 1395x(r)), and the CMS-855I, CAQH and commercial applications treat an MD and a DO the same way.
What differs is the paperwork behind the file: the state board that issued the license the medical school, residency programs accredited through the ACGME or the AOA, and board certification issued by an ABMS member board or an AOA board. Our process and price do not change.
Board certification: how payers treat it
Board certification is verified, not universally required. Under NCQA standards, which most commercial plans follow, a plan that is told a physician holds board certification verifies it with the primary source and records the expiration date. NCQA recognizes ABMS and AOA board certification as the highest level of education and training, so verifying it stands in for verifying residency; for a physician without board certification, the plan verifies residency completion instead (AMA-published NCQA Q&A, 2022). NCQA also accepts other U.S. boards when a plan documents which boards it accepts (NCQA letter, March 16, 2021).
Individual plans can set their own policy for some specialties, and that policy is in the plan's credentialing criteria, not in NCQA. We check each payer's criteria before filing, and we put the board certification expiration date on the same calendar as the license and DEA, because a lapsed date shown on CAQH holds up the next recredentialing.
Physician re-credentialing and revalidation calendar
Credentialing does not end at the effective date. These clocks keep running.
| Clock | Cadence | Source |
|---|---|---|
| CAQH re-attestation | Every 120 days (180 in Illinois) | CAQH quick reference guide |
| Commercial plan recredentialing | Every three years for plans following NCQA standards | NCQA |
| Medicare revalidation | Every 5 years, or sooner if CMS asks | 42 CFR 424.515 |
| Medicaid revalidation | At least every 5 years | 42 CFR 455.414 |
| Medicare change reporting | Ownership change, adverse legal action or practice location change within 30 days; all other changes within 90 days | 42 CFR 424.516(d) |
Maintenance at $99 per physician per year keeps CAQH attested and the expirables current. Each payer cycle is covered in detail on recredentialing and credentialing maintenance.
Physician credentialing questions, answered
What is physician credentialing?
How much does physician credentialing cost?
Do hospitalists and rounding physicians need their own payer enrollment?
Is credentialing different for a DO than for an MD?
Do payers require board certification for physicians?
Can a physician see Medicare patients before enrollment is approved?
Does a physician need to re-credential when changing groups?
What is MD credentialing?
Sources
Primary sources, each read on October 23, 2026.
- 42 CFR 424.520: effective date of Medicare billing privileges
- 42 CFR 424.521: retrospective billing up to 30 days
- 42 CFR 424.515: Medicare revalidation every 5 years
- 42 CFR 424.516: reporting changes (30 and 90 days)
- 42 CFR 424.514 and 42 CFR 424.502: Medicare application fee and the definition of institutional provider
- 42 CFR 455 subpart E: Medicaid enrollment of ordering and referring physicians (455.410) and revalidation (455.414)
- 42 U.S.C. 1395x(r): definition of physician
- CMS consolidated CMS-855I bulletin
- NCQA: credentialing standards and recredentialing
- NCQA letter on accepted specialty boards (2021)
- AMA: NCQA credentialing standards Q&A (2022)
- CAQH ProView provider quick reference guide
Start physician credentialing today
$250 per payer application per physician. CAQH setup $250. New-practice bundle $1,750, $1,400 for each additional physician on the same group and payers.
Prefer to talk first? Call (844) 772-8902. Run from Clearwater, FL, for physicians in Florida and across the United States, by a team with 30+ years of combined billing and credentialing experience.
Updated 2026-10-23. Reviewed by Jacob Greenberg, ClaimCarePro.