Provider enrollment readiness checklist

Payer credentialing applications require a complete documentation package. When an application is submitted with missing information, payers typically issue a request for additional documentation, a communication that can take days or weeks to reach the right person in the practice, delays that compound across multiple payers. Starting with a complete package eliminates this category of delay entirely.

Document readiness also reduces the risk of submitting incorrect information. Discrepancies between what is on an application and what appears in primary source records, a date that doesn't match, a license number that differs, can trigger additional review or application holds. Reviewing all documents before submission catches these issues before they become payer-side delays.

State medical licenses are primary credentials and must be current, in good standing, and without any disciplinary history that has not been disclosed. Most payers require copies of all licenses held, including any in states other than the state where the provider will primarily practice. DEA registration is separately required for any controlled substance prescribing and must also be current.

• State medical license, current, in good standing, no expiration within 90 days
• DEA registration certificate, current, if applicable to the scope of practice
• Board certification documentation, current, if applicable
• Additional state licenses if the provider will see patients in multiple states
• Hospital privileges documentation, if required by the applying payer

Malpractice history is one of the more sensitive documentation areas in credentialing. Payers require a current certificate of insurance showing coverage amounts and policy period, a claims history for any prior malpractice actions, and sometimes an explanation letter for any incidents disclosed. Work history typically requires documentation of the past 5-10 years, with explanation letters covering any gaps of more than 30-90 days.

• Current malpractice insurance certificate with coverage amounts and effective dates
• Malpractice claims history, include full documentation for any pending or resolved matters
• Chronological work history for the past 5-10 years with no unexplained gaps
• Explanation letters prepared for any malpractice actions or employment gaps
• Contact information for prior employers for primary source verification

CAQH ProView serves as the central data repository for most commercial payer credentialing applications. A complete, attested CAQH profile significantly reduces the documentation burden for individual payer applications because payers can pull the relevant information directly from CAQH rather than requiring it to be resubmitted with each application. Providers must authorize each payer to access their profile and must maintain active attestation.

• CAQH ProView account created with a complete profile
• All required documentation uploaded to CAQH (licenses, malpractice, DEA)
• Profile fully attested and within the active attestation window
• CAQH authorization granted to all applying payers
• CAQH attestation reminder scheduled for 90 days from last attestation

Electronic funds transfer (EFT) and electronic remittance advice (ERA) enrollment are typically completed alongside or immediately after credentialing. EFT enrollment establishes direct deposit for payer payments; ERA enrollment establishes electronic delivery of remittance information. Both are important for efficient payment posting and reconciliation. Banking information will be required for EFT enrollment, and clearinghouse information will be required for ERA setup.