Provider Credentialing, CAQH & PECOS Enrollment FAQ
Everything physicians, NPs, PAs, and group owners need to know about payer enrollment timelines, CAQH maintenance, and revalidations.
Detailed Questions & Answers
Physician Credentialing ServicesHow early should we start credentialing for a new physician or clinic location?
Begin credentialing 90 to 120 days before the provider's first scheduled patient day or new office opening. Medicare PECOS typically takes 45–60 days, while commercial HMO/PPO and Medicaid MCO panels average 60–120 days.
What is the difference between Type 1 and Type 2 NPIs?
A Type 1 NPI identifies an individual rendering clinician for their entire career regardless of job changes; a Type 2 NPI identifies a legal business entity, group practice TIN, or facility location.
Can a newly hired doctor bill under another partner's NPI while waiting on credentialing?
No. Billing an uncredentialed permanent provider's services under a credentialed colleague's NPI constitutes improper 'incident-to' or false rendering-provider reporting with commercial payers and Medicare (outside narrow 60-day Locum Tenens Modifier Q6 temporary substitutions).
What forms are required for Medicare Part B group and provider enrollment?
Internet-based PECOS uses CMS-855B to enroll the group clinic, CMS-855I for individual practitioners, CMS-855R (now consolidated within 855I workflows) to reassign benefits to the group TIN, and CMS-588 for Electronic Funds Transfer (EFT).
What happens if a provider's CAQH ProView profile expires?
CAQH attestations expire every 120 days. If a profile lapses into unattested status, commercial payers freeze pending credentialing applications and can suspend active network directory listings. VOPSS re-attests managed profiles every 90 days.
What if a commercial insurance panel says it is 'closed' in our metro area?
When a carrier closes a regional panel, we draft clinical Letters of Appeal highlighting specialty access gaps, hospital admitting privileges, subspecialty procedures, multilingual care, or extended clinic hours to secure panel exceptions.
Do Nurse Practitioners (NPs) and Physician Assistants (PAs) need independent credentialing?
Yes. Most commercial payers, Medicaid MCOs, and Medicare require mid-level practitioners to hold independent enrollments—even if certain follow-up Medicare visits qualify for Incident-To billing.
How often does Medicare require mandatory provider revalidation?
CMS requires enrolled groups and practitioners to complete full PECOS revalidation every 5 years (every 3 years for DMEPOS suppliers). Missing a revalidation due date results in Medicare billing deactivation.
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