Understanding Physician Credentialing: What Providers Need to Know

 If you are launching a new practice, joining a group, or adding payers, credentialing can feel like a maze. You want to treat patients and get paid without delays, yet the process involves detailed checks, strict timelines, and plenty of paperwork. This guide breaks credentialing into clear steps so you know what will be reviewed, how long it typically takes, why applications get denied, and what to prepare up front to prevent slowdowns. You will also see how the right partner can help you move faster and protect your revenue.

 What credentialing is and why it matters

 Credentialing is the verification of a provider’s qualifications, training, licensure, and professional standing by health plans, hospitals, and facilities. It protects patients and payers by confirming you meet standards of care and compliance. Successful credentialing leads to payer participation and privileges, which means in network reimbursement, smoother referrals, and fewer claim denials. If you skip it, or if your credentials lapse, you risk unpaid claims, out of network rates, or inability to see certain patients in the first place.

 How long physician credentialing takes

 Most physicians can expect 60 to 120 days from complete submission to approval. Some scenarios move faster, yet others take longer. Timing depends on:

• Payer volume and processing backlogs

• Completeness and accuracy of your application

• Primary source verifications, such as training, licensure, DEA, and board certification

• Contracting steps after credentialing, including rate negotiation and countersignature

• Facility or hospital medical staff bylaws that include committee meeting dates.

  
  

  Practical tip: start 90 to 120 days before your planned start date. Submit to multiple payers at once, track each application, and respond to requests within 24 to 48 hours. If you use CAQH, keep the profile current and attested

What is checked during credentialing

 Credentialing is a primary source verification exercise. Expect reviewers to confirm:

• Current, unrestricted state licensure DEA registration and any state controlled substance permits

• Education and training, including medical school, residency, fellowship Board certification status, eligibility, and any expiration windows

• Work history for the past five to ten years with explanations for gaps

• Malpractice insurance coverage and limits, plus tail coverage when applicable

• Claims history and any settlements or judgments

• Hospital privileges and good standing letters

• Sanctions or exclusions, for example OIG and SAM databases References or peer recommendations as required by certain payers or facilities

• Identification, NPI, IRS W-9, practice location details, and ownership disclosures

 Facilities often add immunization records, TB screening, BLS or ACLS, and health clearance. Keep a centralized file so you can respond quickly when a payer requests proof.

 Why credentialing can be denied

 Denials usually trace back to one of a few issues:

•  Incomplete or inconsistent application data, such as mismatched dates, missing signatures, or expired documents

• Licensure or DEA problems, including restrictions or pending investigations

• Lapses in malpractice coverage or insufficient policy limits

• Red flags in malpractice or disciplinary history without clear explanations

• Unresolved sanctions or exclusions

• Failure to meet network participation criteria due to panel closures or specialty oversaturation

• Missed deadlines for responses or re-attestation

 Most denials can be prevented with early file reviews and a second set of eyes on your application. If you are denied due to a closed network, ask about an exception request, quality metrics, or geographic need that might support reconsideration.

 What happens if a provider is not credentialed

 Working before credentialing is complete can create serious revenue and compliance problems. Common outcomes include:

• Claims paid at out of network rates or denied entirely

• Retroactive effective dates that do not cover initial visits

• Inability to admit or treat patients at facilities that require medical staff membership

• Contract breaches with groups or employers that expect active payer participation

• Delays in cash flow that impact payroll, rent, and supplies

 If you must start seeing patients, check whether a payer allows retroactive effective dates after contracting. Get that policy in writing. Otherwise, schedule self pay patients transparently or delay certain visits until effective dates are confirmed.

 A simple checklist to prepare your credentialing documents

 Create a digital folder for each provider and keep everything current. Use this checklist to reduce back and forth:

•  Government ID, NPI, Social Security, and birth date

• Current CV with month and year for all positions, no gaps

• Medical school diploma and training certificates

• State license, DEA, and any state controlled substance permit

• Board certification or eligibility letter with expiration dates

• Malpractice insurance face sheet, claims history, and tail documentation

• Hospital privileges verification or admitting arrangements letter

• CAQH profile login, attestation date, and document uploads

• IRS W-9, practice entity documents, and ownership structure

• Practice locations, hours, appointment phone, fax, and secure email

• State and federal exclusions check results and explanations if any issues exist

• Immunizations and current BLS or ACLS, if required by facilities

 Set calendar reminders 90 and 60 days before any expiration date. Consistent maintenance keeps recredentialing smooth and prevents sudden coverage disruptions.

 How to avoid delays and keep applications moving

•  Standardize your data. Use one master file for names, addresses, and tax IDs to prevent typos and mismatches.

• Align start dates with realistic timelines. Submit early and confirm committee schedules for facilities.

• Respond fast. Many payers pause files after a single missing item. Same day replies save weeks.

• Track every application. Maintain a status log with submission dates, ticket numbers, and who you spoke with.

• Verify CAQH monthly. Re-attest whenever a change occurs, including a new address or added taxonomy.

 Where expert help accelerates results

 Credentialing success comes from precision and persistence. A specialized partner can gather documents, complete applications, manage CAQH, perform primary source checks ahead of payers, and follow up consistently until you have effective dates and contracts in hand. Terra Nova supports individual and small group practices with full service credentialing and payer contracting, plus ongoing billing and practice management so you can protect cash flow from day one.

** If you are expanding or opening a new office in the Carolinas, our team can align credentialing with your onboarding plan and revenue targets. When it fits naturally in your planning, explore our provider credentialing solutions charlotte to see how a structured approach shortens timelines and reduces denials.

Summary: stay credentialed and stay paid

You want credentialing to be predictable, fast, and accurate. Plan for 60 to 120 days, verify that your documents are complete, and keep a master file that you can update at a moment’s notice. Most denials and delays can be avoided with careful preparation, precise applications, and steady follow up. If you want a partner to handle the details and keep your revenue moving, Terra Nova is ready to help with end to end credentialing and billing support. For broader financial operations, learn how a charlotte medical billing company can integrate credentialing with claims, denials, and reporting.

If you are assessing broader process improvements, you might find our guidance on healthcare revenue cycle management useful as you map your next steps. Call Terra Nova today at 704-420-2710 to start your credentialing plan.