05
Insurance Credentialing
Medicare via PECOS, Medicaid, and 8 commercial payers — apply all simultaneously, track every timeline
Credentialing takes 60–120 days per payer — start all applications the same week
Do not credential with one payer at a time. Submit Medicare, Medicaid, and all commercial payer applications within the same 1–2 week window. Each one runs its own independent timeline. Starting them sequentially adds 6–12 months of delay before your practice can bill insurance.
A Part 1 — Medicare Enrollment via PECOS
Medicare enrollment is required to bill Medicare directly. You apply through PECOS (Provider Enrollment, Chain and Ownership System) using the CMS-855I form. Fee: $688 — verify current amount at time of application.
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Prerequisites before starting PECOS
- Active state NP license in each state where you will see Medicare patients
- Type 1 NPI — your individual NPI number (from Module 02)
- Type 2 NPI — your organization NPI (from Module 02)
- EIN — your business Employer Identification Number (from Module 02/04)
- CAQH ProView profile complete and attested (from Module 03)
- Malpractice insurance active (from Module 04)
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Create your PECOS account
Go to pecos.cms.hhs.gov and log in with the same CMS I&A credentials you used for NPPES. Select “My Enrollments” → “Add Enrollment.”
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Complete the CMS-855I application — 12 sections
- Section 1: Reason for application (new enrollment)
- Section 2: Provider information — NPI, legal name, SSN, date of birth
- Section 3: Practice location — address where you see Medicare patients
- Section 4: Medicare specialty — select “Nurse Practitioner” (specialty code 50)
- Section 5: Reassignment of benefits — if billing under a group, reassign here; if solo, select individual
- Section 6: Final adverse legal actions — any criminal history, exclusions, sanctions
- Section 7: Billing agency — list if you use a third-party billing company
- Section 8: Individual authorized official — your signature authority
- Section 9: Supporting documentation — upload license, malpractice certificate, IRS letter
- Payment: $688 non-refundable application fee via credit card
Medicare processing timeline
PECOS online applications typically take 45–90 days. Your MAC processes your application and will email if any information is missing. Respond within 30 days of any MAC request or your application is rejected. Check PECOS weekly for status updates.
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Find your Medicare Administrative Contractor (MAC)
Your MAC is the regional CMS contractor that processes your enrollment. Call them directly to check status — much faster than PECOS messaging.
- ↗ CMS — Find Your MAC by State
- TX/OK/LA/AR/CO/NM: Novitas Solutions — 1-855-252-8782
- NY/CT/MA/RI/VT/NH/ME: National Government Services — 1-888-379-9132
- FL/PR/VI: First Coast Service Options — 1-888-454-1871
- WA/OR/ID/AK/HI: Noridian Healthcare Solutions — 1-855-609-9960
- MD/VA/NC/SC/WV/DC/DE: Novitas Solutions — 1-855-252-8782
B Part 2 — Medicaid Enrollment
Medicaid enrollment is done through your state Medicaid agency, not CMS. Most states also have MCOs — you must enroll with the state AND each MCO separately.
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State Medicaid portals for your practice states
| State | Medicaid Portal | Key MCOs |
|---|---|---|
| TX | TMHP ↗ | Centene, Molina, UHC Community Plan |
| NY | eMedNY ↗ | Fidelis, Healthfirst, MetroPlus |
| FL | FMMIS ↗ | Staywell, Sunshine Health, Simply Healthcare |
| CO | HCPF ↗ | Colorado Access, Rocky Mountain, Anthem |
| WA | Apple Health ↗ | Amerigroup, Community Health Plan, Molina |
| MD | Maryland MMCP ↗ | Priority Partners, Amerigroup, CareFirst |
| NH | NH DHHS ↗ | NH Healthy Families, WellSense |
| NM | NM HSD ↗ | Presbyterian, BCCC, UHC Community Plan |
| IA | Iowa Medicaid ↗ | UHC Community Plan, Molina, Meridian |
C Part 3 — Commercial Payer Credentialing
Apply to all major commercial payers simultaneously. Each uses your CAQH data but requires its own application. Processing typically takes 60–90 days per payer.
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The 5 major commercial payers — direct application portals
| Payer | Application Portal | Timeline | Notes |
|---|---|---|---|
| Aetna | Aetna Provider ↗ | 60–90 days | Uses CAQH; submit online first, then CAQH review begins |
| Blue Cross Blue Shield | BCBS Provider ↗ | 60–90 days | Each state plan is separate; apply to your state plan’s portal |
| UnitedHealthcare | UHC Provider ↗ | 90–120 days | Longest timeline — start first; separate Commercial and Community Plan apps |
| Cigna | Cigna for HCP ↗ | 60–75 days | Call 1-800-88CIGNA to initiate; uses CAQH |
| Humana | Humana Provider ↗ | 60–90 days | Important for Medicare Advantage patients; uses CAQH |
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Follow up every 14 days by phone — not email
Applications that are not actively followed up on often sit without action. Call each payer’s provider credentialing line every 14 days. Get the name of the representative and log every call.
- Aetna Credentialing: 1-800-353-1232
- UHC Provider Services: 1-877-842-3210
- Cigna Provider Services: 1-800-882-4462
- Humana Provider Services: 1-800-626-2741
- BCBS: Contact your state plan’s provider relations line
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Use the Credentialing Tracker to log every application
Track every payer application — submission date, confirmation number, status, follow-up notes, and effective date — in your personal tracker. It saves automatically to your account so you can check status from any device.
📋 Open Credentialing Tracker →
Always get your effective date in writing
Once approved, confirm your effective date — the date from which claims can be submitted. Some payers backdate to your application date; others use approval date. Claims submitted before your effective date will be denied.