Credentialing with Insurers — A Friendly Step-by-Step for PT/OT/SLP

Quick checklist

• NPI(s): Type 1 (each clinician) and Type 2 (your organization/group if you’ll bill as a group). Apply in NPPES and see the CMS NPI fact sheet.
• Documents: state license(s), government-issued ID, malpractice/PLI (individual and clinic), W-9/EIN, address and phone, education/employment history, references (if requested).
• CAQH ProView: complete profile, upload docs, and attest so plans can use your data. Guide: CAQH ProView Provider User Guide (PDF).
• Medicare: set up CMS Identity & Access and enroll via PECOS; MAC contacts: CMS enrollment assistance or the MAC contact list (PDF).
• Medicaid: enroll with your State Medicaid, then Medicaid MCOs. Start here: Medicaid state overviews.
• Commercial plans: request participation (portal/email/phone) and share your CAQH ID.
• Tracking: maintain a grid of payer contacts, submitted dates, reference numbers, and effective dates.

Compliance: This guide is educational—not legal, coding, or contracting advice. Always follow federal/state rules and each payer’s requirements.

Step-by-step credentialing

1) Get your NPIs (it’s quick)

Apply for your individual NPI (Type 1) and, if you’ll bill as a clinic or group, your organization NPI (Type 2) in NPPES. CMS explains the Type 1 vs Type 2 distinction here: NPI fact sheet (PDF).

2) Set up CAQH ProView

Create or update your CAQH ProView profile. Upload licenses, malpractice, education, and work history, then attest so plans can view your data. Most plans expect re-attestation on a regular cadence (commonly every 120 days). See the official CAQH Provider User Guide (PDF) for what’s required.

3) Enroll in Medicare via PECOS

Set up a CMS Identity & Access account for each provider and, if staff will submit on a provider’s behalf, add surrogate access. Then complete enrollment in PECOS using the appropriate CMS-855 application(s). For help, contact your Medicare Administrative Contractor (MAC): Enrollment assistance or the nationwide MAC list (PDF).

4) Enroll in your State Medicaid (then MCOs)

Start with State Medicaid enrollment, then add Medicaid Managed Care Organizations (MCOs) your patients use. Requirements and portals vary—use Medicaid.gov to jump to your state’s official site: Medicaid state overviews.

5) Join commercial plans (simple outreach works)

Call the plan’s provider services/credentialing line (usually on the back of the member’s card) or use the plan’s portal to request participation. Your opening email can be as simple as: “We’re a new PT/OT/SLP clinic seeking network participation. Our group NPI is [Type 2], EIN [####], and clinicians’ NPIs and CAQH IDs are attached.” Keep your CAQH profile attested and ready; most plans pull directly from CAQH to verify details.

6) Keep credentials current (and add clinicians fast)

Maintain a simple grid with payer contacts, application dates, reference numbers, and effective dates. For new hires, plans often accept a short form or portal submission to add a rendering provider to your existing group contract—share the clinician’s NPI, license, CAQH ID, and start date. For Medicare/Medicaid, affiliate the provider appropriately (e.g., 855R in PECOS) before billing under the group.

Call the payer: short scripts that work

• Credentialing status: “Hi, I’m calling to check the status of our network participation request for [Clinic Name]. We submitted on [date]. Our TIN is [####]. Is anything missing? What’s the next step?”
• Panel closed: “We serve [pediatrics/neuro/vestibular/etc.] in [ZIP]. Are there exceptions for access or clinical gaps? May we submit data on wait times or referrals?”
• Add a provider: “We’re adding [Provider Name], NPI [#####], start date [date]. What’s your preferred process to add them to our group?”

Timelines & expectations

Credentialing timelines vary by payer and state. A straightforward commercial plan can complete in weeks; Medicare and some Medicaid agencies can take longer depending on volume and background checks. The best accelerator is clean paperwork and quick responses—plus calling provider services if anything stalls.

Common pitfalls to avoid

• Letting CAQH lapse: re-attest on schedule so plans see a “current” profile (CAQH guide).
• Mismatched data: ensure your legal name, TIN, address, NPIs, and license numbers match across NPPES, CAQH, and applications (NPI & NPPES resources: NPPES · NPI Registry).
• Skipping PECOS/I&A setup: for Medicare, use the official systems—MACs can help if you’re stuck (PECOS · Manage your enrollment).
• Not calling: provider services and credentialing teams are there to answer questions—use them.

Tip: While you wait for network approvals, set up eligibility checks and clean billing workflows so you can move quickly once effective dates arrive.

FAQs

What’s the difference between credentialing and contracting?

Credentialing verifies your clinicians and clinic; contracting establishes rates and effective dates. Some plans run these in parallel; others credential first, then send a contract.

Do I need both individual and group NPIs?

Yes—each clinician has a Type 1 NPI; your organization has a Type 2 NPI if you bill as a group. CMS explains the difference here: NPI fact sheet (PDF).

How often do I re-attest CAQH?

Generally every 120 days (some states use 180). If you miss it, plans may pause processing until your profile shows “current.” Reference: CAQH ProView Provider Guide.

Where do I get help with Medicare enrollment?

Your regional Medicare Administrative Contractor (MAC) offers phone support and tutorials. Start with CMS’s enrollment contacts page, then log into PECOS. Enrollment assistance & contacts · PECOS login.

How do I find my state’s Medicaid enrollment?

Use Medicaid.gov’s state overview list to jump to your state’s official site and provider enrollment page: Find your state.