Medicare
PECOS is Medicare’s online enrollment system. Prepare the provider or organization’s application, supporting documents and authorized signatures, then track outstanding requests.
PROVIDER & PAYER CREDENTIALING
Provider Credentialing & Payer Enrollment Services
A coordinated 12-step process, from provider data collection through enrollment and ongoing monitoring.
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Provider credentialing, payer enrollment and ongoing maintenance
Keep provider licenses, identifiers, application records and payer requirements organized in one coordinated process. Clarinza RCM supports document collection, enrollment submissions and follow-up on outstanding requests.
Credentialing and enrollment requirements vary by payer and provider. Our workflow tracks each application’s status, missing documents and next action, with ongoing attention to renewals and revalidation.
Step 1 of 12
Provider Data Collection
Establish a consistent provider information file.
- Gather licenses, DEA certificate, board certifications, and diplomas.
- Collect malpractice insurance history, CV, and work history with no gaps.
- Confirm NPI (Type 1 individual / Type 2 organizational) numbers are active.
How this connects
The records and open questions from this stage support the next step: CAQH ProView Profile Setup & Maintenance. Keep responsibilities and outstanding actions visible as work moves forward.
Step 2 of 12
CAQH ProView Profile Setup & Maintenance
Keep shared provider data aligned with supporting documents.
- Create or update the provider's CAQH profile with complete, current data.
- Attach required documents and re-attest every 120 days as required.
- Ensure CAQH data matches what will be submitted to each payer.
How this connects
The records and open questions from this stage support the next step: Primary Source Verification (PSV). Keep responsibilities and outstanding actions visible as work moves forward.
Step 3 of 12
Primary Source Verification (PSV)
Coordinate verification through authorized sources.
- Verify education, training, licensure, and certifications directly with issuing bodies.
- Check NPDB (National Practitioner Data Bank) for malpractice or sanction history.
- Confirm good standing via OIG/SAM exclusion list and state license board checks.
How this connects
The records and open questions from this stage support the next step: Payer Enrollment Application Preparation. Keep responsibilities and outstanding actions visible as work moves forward.
Step 4 of 12
Payer Enrollment Application Preparation
Prepare applications for each selected payer.
- Identify target payers (Medicare, Medicaid, commercial, managed care plans).
- Complete payer-specific enrollment applications (e.g., CMS-855I/855B for Medicare).
- Attach W-9, voided check/EFT form, and group billing information as required.
How this connects
The records and open questions from this stage support the next step: Medicare & Medicaid Enrollment (PECOS). Keep responsibilities and outstanding actions visible as work moves forward.
Step 5 of 12
Medicare & Medicaid Enrollment (PECOS)
Track Medicare and state Medicaid enrollment separately.
- Submit enrollment through PECOS for Medicare and state portals for Medicaid.
- Track application status and respond promptly to Additional Documentation Requests (ADRs).
- Secure the Medicare/Medicaid effective date and PTAN.
How this connects
The records and open questions from this stage support the next step: Commercial Payer Enrollment. Keep responsibilities and outstanding actions visible as work moves forward.
Step 6 of 12
Commercial Payer Enrollment
Maintain visibility into commercial payer applications.
- Submit applications to commercial payers (Aetna, Cigna, UHC, BCBS, etc.).
- Follow up on application status weekly to avoid stalled files.
- Confirm provider is loaded correctly into the payer's directory system.
How this connects
The records and open questions from this stage support the next step: Contracting & Fee Schedule Negotiation. Keep responsibilities and outstanding actions visible as work moves forward.
Step 7 of 12
Contracting & Fee Schedule Negotiation
Clarify participation terms before acceptance.
- Review participating provider agreements and reimbursement terms.
- Negotiate fee schedules where the payer and network allow.
- Confirm effective dates, term length, and network participation status.
How this connects
The records and open questions from this stage support the next step: Hospital & Facility Privileging (if applicable). Keep responsibilities and outstanding actions visible as work moves forward.
Step 8 of 12
Hospital & Facility Privileging (if applicable)
Coordinate facility requirements when applicable.
- Submit privileging applications to hospital medical staff offices.
- Coordinate with the Medical Staff Office / Credentials Committee for approval.
- Track privileging renewal cycles alongside payer credentialing timelines.
How this connects
The records and open questions from this stage support the next step: Committee Review & Approval. Keep responsibilities and outstanding actions visible as work moves forward.
Step 9 of 12
Committee Review & Approval
Keep outstanding review questions visible.
- Payer or facility credentialing committee reviews the completed file.
- Respond to any requests for clarification or missing documentation.
- Receive formal approval notice and effective date confirmation.
How this connects
The records and open questions from this stage support the next step: Provider Enrollment Confirmation & Linkage. Keep responsibilities and outstanding actions visible as work moves forward.
Step 10 of 12
Provider Enrollment Confirmation & Linkage
Check that provider, location and group records align.
- Confirm the provider is linked correctly to the group/TIN in each payer system.
- Verify the provider appears in-network and in the payer's online directory.
- Update the practice management system with payer IDs and effective dates.
How this connects
The records and open questions from this stage support the next step: Go-Live & Claims Release. Keep responsibilities and outstanding actions visible as work moves forward.
Step 11 of 12
Go-Live & Claims Release
Coordinate billing readiness with confirmed payer effective dates.
- Release held claims for dates of service on or after the effective date.
- Notify billing/RCM team that the provider is clear to bill under the new payer IDs.
- Monitor first claims closely to confirm correct adjudication.
How this connects
The records and open questions from this stage support the next step: Ongoing Monitoring & Compliance Tracking. Keep responsibilities and outstanding actions visible as work moves forward.
Step 12 of 12
Ongoing Monitoring & Compliance Tracking
Keep renewals and record changes on the calendar.
- Track license, DEA, and malpractice insurance expiration dates continuously.
- Maintain a master credentialing calendar across all providers and payers.
- Flag upcoming re-credentialing deadlines well before they are due.
How this connects
Findings from this stage inform the next cycle. Review recurring issues with the practice and update the relevant worklists and preparation steps.
Different enrollment routes. One organized record.
Medicaid
State Medicaid programs have their own enrollment processes. Confirm the relevant state requirements and track each application separately from Medicare.
Commercial payers
Application channels, network availability and participation terms vary. Follow each payer’s requests and confirm effective dates and group linkage before coordinating billing readiness.
Enrollment decisions belong to the payer. Approval and universal completion timelines cannot be guaranteed. Medicare uses PECOS; Medicaid applications follow the relevant state process.
CMS provider enrollment information ↗BEYOND ENROLLMENT
Stay ready for what’s next.
Credentialing is an ongoing process. Keep renewals, updates, and revalidations in view.
CAQH re-attestation every 120 days
Keep the profile active and visible to payers.
Payer re-credentialing cycles
Typically every 2–3 years depending on the plan.
License, DEA, and board certification tracking
Renewal tracking with advance alerts.
Malpractice insurance renewal
Verification and updated certificate submission.
Demographic and affiliation updates
Address, TIN, or group affiliation changes across enrolled payers.
Medicare and Medicaid revalidation
Medicare typically every 5 years via PECOS, plus Medicaid revalidation.
Payer directory audits
Proactive audit of the provider’s payer directory listings for accuracy.
Provider records
Keep licenses and supporting documents current
Payer requirements
Track each payer’s specific renewal requests
Enrollment changes
Review locations, group linkage and effective dates
GOOD QUESTIONS. CLEAR ANSWERS.
Let’s make things clearer.
A little clarity before your next step.
How long does credentialing take?
Timelines vary by payer. We do not publish turnaround guarantees that are not in the source document.
Is re-credentialing a separate service?
Yes. Re-credentialing and maintenance covers CAQH attestation every 120 days, typical 2–3 year payer cycles, and Medicare revalidation (typically every 5 years).
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