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Physician Credentialing Checklist:
Hassle-Free Guide
Credentialing is one of the most detail-heavy parts of running a medical practice. Between gathering documentation, submitting applications to multiple payers, and tracking everything across different timelines, it’s easy for small errors to create big delays. And even experienced teams can run into setbacks if the process isn’t well-organized. Having a streamlined process isn’t just nice to have, it is essential.
Whether you’re bringing on a new provider or updating existing credentials, this checklist gives you a way to stay organized and avoid costly setbacks.
What is Credentialing?
Physician credentialing is the process of verifying that healthcare providers are qualified to treat patients and receive reimbursement from insurers. It includes checking education, licensure, work history, and insurance participation.
The Physician Credentialing Checklist
Pre-Application Checklist
Before you submit any forms, gather the required information and documents for a smooth credentialing experience:
- Initial Research and Professional Information
- Personal Information and Documents
- Education and Training Documents
- Professional Licenses and Certifications
- Work History & Experience
- Malpractice Insurance and Claims History
- Professional References
Submitting the Credentialing Application
Credentialing forms must be submitted to each payer, and each has its own requirements. Errors or omissions, no matter how small, can significantly delay approval. Follow each payer’s specific instructions and double-check details like dates, addresses, and group affiliations.
Include:
- Educational history
- Current medical license, DEA registration, and board certification
- Work history with explanation of any gaps
- Evidence of Continual Malpractice Coverage
- Professional references
- Hospital privilege or hospital affiliation
- CAQH enrollment
Verification of Receipt
After submitting the application, payers will often send an acknowledgment-but not always. If you don’t hear back, follow up directly to confirm receipt and check status.
Follow-Up and Monitoring
Processing times vary widely-some payers respond in 30 days, others take 90–120 days or more. Delays are common, which is why consistent follow-up is key to avoiding credentialing-related denials.
- Check-in regularly with payers
- Keep credentialing and billing teams aligned
- Track responses and enrollment confirmations
Recredentialing
Credentialing doesn’t end once the provider is approved. Most insurers require recredentialing every 2–3 years.
- Set reminders well in advance of recredentialing dates
- Monitor expiring documents like licenses and malpractice certificates
- Reattest CAQH profiles regularly
- Audit enrollment status at least twice a year
Download the Provider Credentialing Checklist:
Credentialing Scenarios
Credentialing can look a little different depending on your situation. Whether you’re bringing a new provider into an established group or starting a practice from the ground up, here are some examples that show you what you can expect and where to focus your efforts.
Adding a New Provider
Bringing a new provider into your group might feel straightforward, but credentialing missteps at this stage are common. Here are the steps to keep billing on track from day one.
- Updated and attested CAQH profile
- Group needs to provide a list of payers they are currently contracted with
- Supply insurance companies with Tax ID (W9 with pay-to address and CP 575/147 C letter for group) and upload to your CAQH profile.
- identify in CAQH which hospitals you plan to have privileges with. If you do not have hospital privileges, establish an ‘admitting arrangement’ with another provider in your area, or determine which hospitalist group/ER you will use for admitting arrangements.
- Upload new malpractice policy or updated current policy to CAQH
- List group’s primary billing(type II NPI) and tax ID on applications
- List group’s Medicare PTAN that you will be linked to in your Medicare application to link to the new group
Opening a New Practice
Starting a new practice means credentialing at both the provider and organizational level. From setting up your Tax ID to enrolling every location, this checklist will help you lay a strong foundation.
- Establish group in your state – obtain tax ID from the IRS
- Download electronic file when obtaining EIN (called CP-575)
- Obtain service address
- Apply for Group NPI
- Ensure CAQH profile is updated and attested – authorize insurance companies access to your profile
- Identify payers to credential with
- Complete W9
- Hospital credentialing process needs to be underway
- Set up a permanent office phone/fax that is listed on CAQH and applications
- Obtain a malpractice policy
- Applying with medicaid: business license, articles of incorporation, group/practice’s general commercial liability insurance and worker’s comp insurance, and CLIA cert
- Start contacting payers
Credentialing Documents for Physicians
Below is a full list of documents payers typically require. Requirements may vary by state and insurer, so check each payer’s portal to confirm.
Providers should have the following documents ready:
- Personal information like email address, street address, phone, etc.
- Driver’s license
- Social Security card
- Recent photograph signed and dated in the margin
- Medicaid number
- Medicare number
- Copy of National Provider Identifier (NPI#) documentation and confirmation letter
- UPON number
- Federal Tax ID number
- Permanent Resident Card, Green Card or visa status for non-US citizens
- Copy of all current active state license wallet card(s) and wall certificate with expiration date and number
- Copy of current Federal DEA and current State Controlled Substance Registrations or certificate(s)
- Copy of medical licenses, medical school diploma, and training certificate(s), including internships, residencies, and fellowships
- Copy of current Board Certificate, including the name of the issuing board and dates of board certification/recertification
- Surgical logs
- Documentation of hospital privileges
- Completed Delineation of Privileges Form
- Completed Locum Tenens Practice Experience Form (if applicable)
- Work history including all practice locations and employment affiliations
- Malpractice claims history with details
- Third-party documentation (i.e., court documents, dismissals) for all malpractice/disciplinary actions OR completion of appropriate explanation form (if applicable).
- Certificate of malpractice insurance coverage or declaration page (face sheet) of policy (if applicable)
- Case log from the last 24 months (if applicable)
- 10-year insurance claims report
- Current Curriculum Vitae with complete professional history in chronological order and no gaps (month and year must be included)
- Three written letters of recommendation from providers who have directly observed the candidate in practice within the past year, assessing clinical competence and specifying dates observed
- ACLS/BLS certification
- DEA certificate
- Mammo #s and MQSA (if applicable).
- Current CME (CME activity for the past three years)
- Residency diploma
- Military discharge record -Form DD-214 (if applicable).
- Copies of current immunization records and most recent TB test results (if available)
- Copy of NBME, FLEX, USMLE, or SPEX scores
- Copy of Any: BLS, ACLS, ATLS, PALS, APLS, NRP certificate(s)
- If a foreign graduate, ECFMG certificate number and info on Fifth Pathway
Credentialing documents for Physician Assistants & Advanced Practice Nurses
Physician assistants and nurses have slightly different credentialing requirements than physicians.
Here’s what they typically need to submit:
- Personal information like email address, street address, phone, etc.
- Recent photograph signed and dated in the margin
- Medicaid number
- Medicare number
- Copy of National Provider Identifier (NPI#) documentation and confirmation letter
- Federal Tax ID number
- Permanent Resident Card, Green Card or visa status for non-US citizens
- Copy of all current active state license wallet card(s) and wall certificate with expiration date and number
- Copy of current Federal DEA and current State Controlled Substance Registrations or certificate(s)
- Copy of college/university diploma and training certificate(s)
- Current CME (CME activity for the past three years)
- Completed Delineation of Privileges Form
- Completed Locum Tenens Practice Experience Form (if applicable)
- Work history including all practice locations and employment affiliations
- Current CV with complete professional history in chronological order and no gaps (month and year must be included)
- Case log from the last 24 months (if applicable)
- Immunization records
- Diploma and transcripts
- Three professional letters of recommendation
- Driver’s license
- Social Security card
- Military discharge record -Form DD-214 (if applicable).
- Copies of current immunization records and most recent TB test results (if available)
- Focused Professional Practice Evaluation
- An Ongoing Professional Practice Evaluation
Make Credentialing Easier
Credentialing can be overwhelming, but with the right process, it doesn’t have to be a headache. Keep these tips in mind to avoid unnecessary delays and keep your credentialing process moving smoothly:
- Start early: Applications take time. Begin at least 90–120 days in advance.
- Keep contact info up-to-date: Missed emails or calls can delay approvals.
- Know your state’s requirements: Each state has its own requirements and rules.
- Stay organized: Keep documents in one place so they’re easy to update and submit.
- Outsource: Credentialing specialists can help you avoid costly mistakes.
How Claimocity Can Help
Credentialing might be a behind-the-scenes task, but it has a direct impact on your revenue and your ability to treat patients. Claimocity makes it easier to get providers credentialed quickly, avoid denials, and keep your operations running smoothly.
Our credentialing solution includes:
- Accelerated initial credentialing for quicker patient engagement
- Expedited resolution of billing-related issues
- Timely fulfillment of all deadlines and requests
Don’t let credentialing delays jeopardize your revenue. Take the stress out of credentialing and let Claimocity handle the heavy lifting so you can get credentialed faster and paid on time. Book a demo today.
