Get Approved Fast: Medicare Enrollment & CMS Credentialing Made Easy (2025)

Credentialing isn’t just paperwork, it’s your ticket to getting paid. Whether you’re a new provider or joining a new group, CMS credentialing is a must. Without it, you can’t bill Medicare or Medicaid, and that means no reimbursements.

In this quick guide, we’ll walk you through the CMS credentialing process so you can stay compliant, get approved faster, and protect your revenue.

What is CMS Credentialing?

Credentialing is the process through which healthcare providers are evaluated and approved to participate in Medicare and Medicaid programs. It involves verifying a provider’s qualifications and ensuring compliance with program standards to determine eligibility for billing these federal and state-sponsored programs. This process is essential for providers who want to receive reimbursement for services provided to beneficiaries of these programs.

CMS Credentialing Requirements for U.S. Healthcare Providers

Whether you’re a physician, nurse practitioner, therapist, or facility, CMS credentialing ensures you meet federal standards to serve Medicare and Medicaid patients. Here’s everything you need to know to get started and stay in good standing.

Start with Your National Provider Identifier (NPI)

Before anything else, you must apply for a 10-digit NPI through the National Plan and Provider Enumeration System (NPPES). This number is essential for all Medicare and Medicaid billing and identifies you as a healthcare provider. The NPI application requires basic information like your name, credentials, tax ID, and practice location.

Hold a Valid, Unrestricted State License

CMS requires you to have an active license to practice in the state where you provide care. If your license is expired or restricted, your application will be denied. For some specialties, you may also need board certifications or advanced training.

Submit the Correct CMS Enrollment Form or Use PECOS

Once your NPI and license are in place, you’ll need to submit a CMS-855 form or apply online through PECOS (Provider Enrollment, Chain, and Ownership System).

Here’s a quick breakdown of the forms:

Form	Purpose
CMS-855I	For individual practitioners (doctors, nurses, therapists)
CMS-855B	For group practices and clinics
CMS-855A	For institutional providers (hospitals, nursing homes)
CMS-855R	For reassigning benefits to a group or organization

Undergo Review by a Medicare Administrative Contractor (MAC)

Once your enrollment is submitted, it’s reviewed by a Medicare Administrative Contractor (MAC), a regional CMS partner that validates credentials, licenses, and documents. If anything is missing, the MAC will request additional information instead of rejecting your application outright.

Sign the Medicare Participation Agreement

After successful credentialing, providers must sign the Medicare Participation Agreement, confirming that they:

• Accept Medicare’s fee schedule as full payment
• Follow all CMS coding and billing rules
• Submit clean, accurate claims
• Deliver medically necessary care and uphold quality standards

Compliance with Federal & State Requirements

Credentialing requires ongoing compliance with federal and state regulations. Providers must adhere to HIPAA privacy standards, Medicare CoPs, Affordable Care Act enrollment requirements, and CMS billing updates. On the state level, maintain a valid license, state Medicaid enrollment, and follow MCO rules. Telehealth providers must comply with telehealth laws and cross-state licensure.

Pass Background Checks and Exclusion Screenings

CMS conducts background checks every 3–5 years, including criminal history, Medicare/Medicaid exclusions, malpractice history, and any disciplinary actions.

They look into:

• Federal and state criminal history
• Medicare/Medicaid exclusions
• Malpractice history and settlements
• Disciplinary actions or license sanctions

Carry Active Malpractice Insurance

You must have current malpractice insurance coverage that meets CMS and hospital requirements. Typically, coverage should be at least:

• $1 million per claim
• $3 million annual aggregate

Meet CMS Quality and Reporting Standards

Providers must meet Conditions of Participation (CoPs) and Conditions for Coverage (CfCs), participate in MIPS, and submit Clinical Quality Measures (CQMs).

• Meeting Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• Participating in MIPS (Merit-Based Incentive Payment System), if eligible
• Submitting Clinical Quality Measures (CQMs)

Understand Provider-Specific Requirements

Non-physician practitioners (e.g., PAs, NPs) may need specialty certifications. Telehealth providers must follow state licensure rules, and pharmacists, labs, and DME suppliers may require additional documentation or inspections.

Overview of CMS Credentialing Process and Recredentialing Timeframes

Here’s the information organized in a table format:

Process	Details
Initial Credentialing	Submit CMS-855 forms via PECOS to enroll for Medicare and Medicaid. Typically completed in 30-90 days.
Re-credentialing Frequency	Required every 3-5 years to maintain eligibility.
Recredentialing Notification	Providers receive a notification 6 months before credentials expire.
Recredentialing Process	The re-credentialing process usually takes 30-60 days.
Early Review Triggers	Early reviews may occur due to changes in practice location, TIN, disciplinary actions, or malpractice history.
Tracking & Compliance	Providers should track credentialing dates, stay updated on CMS regulations, and notify PECOS or MAC of any significant changes to avoid delays.

Common CMS Credentialing Mistakes (And How to Avoid Them)

Credentialing errors can cause significant delays in the Medicare enrollment process. Understanding and addressing these common mistakes can help avoid unnecessary complications.

Missing NPI or Invalid License

When you fail to submit a National Provider Identifier (NPI) or submit an expired or restricted license it can stop the credentialing process. It is crucial that you submit your NPI and your license is active and unrestricted to avoid denials.  

Incomplete CMS Forms

Incomplete CMS-855 forms or PECOS applications can delay processing. Missing documents like tax IDs or proof of licensure prevent CMS from reviewing your application, causing unnecessary delays.

Wrong CMS-855 Form Used

Using the incorrect CMS-855 form (I, B, A, or R) based on your provider type is a common mistake. Submitting the wrong form can result in rejection or significant delays, so ensure you’re using the correct one for your provider category.

No Response to MAC Requests

Failure to respond to requests from your Medicare Administrative Contractor (MAC) can lead to denial or closure of your application. Always monitor emails from MAC and respond promptly (within 7–14 days) to avoid delays.

Issues with Background Checks

Delays can occur if there are discrepancies in criminal history or malpractice records. It’s important to review background checks in advance to avoid surprises during credentialing.

Failure to Track Revalidation Dates

Medicare requires revalidation every 3–5 years. Missing these dates can lead to loss of enrollment. Stay on top of revalidation to maintain continuous Medicare participation.

Incomplete or Incorrect Documentation

Incorrect or outdated documentation (e.g., tax IDs or W-9 forms) can result in delays. Ensure all documents are current and accurate to prevent issues with your application.

CMS Delegated Credentialing Requirements

Delegated credentialing refers to the process where a healthcare organization, such as an insurance plan or managed care organization (MCO), is authorized to handle credentialing tasks on behalf of CMS-participating providers. While CMS allows organizations to delegate credentialing responsibilities, they must still adhere to specific requirements and standards.

Here are the key CMS delegated credentialing requirements:

Written Delegation Agreement

A formal agreement must be in place between the health plan or MCO and the delegated entity, outlining responsibilities, processes, and compliance requirements. The agreement should specify that the delegated organization will comply with CMS regulations and maintain accountability for credentialing tasks.

Compliance with CMS Standards

The delegated entity must follow the same credentialing standards established by CMS, ensuring that they meet federal guidelines, including verification of provider’s qualification, licenses, and certification while ensuring compliance with HIPAA privacy standards. 

 Ongoing Monitoring and Audits

CMS needs ongoing oversight to ensure that the delegated entity is meeting credentialing standards. This includes regular audits and monitoring. 

Record Keeping and Documentation

All credentialing records must be maintained in a secure and accessible manner. The delegated entity must ensure that the documentation is up to date and available for CMS reviews or audits. 

Credentialing Timelines

Delegated entities are required to adhere to CMS timelines for credentialing and re-credentialing:

• Initial credentialing should be completed in a timely manner to avoid payment delays.
  
• Recredentialing should be done every 3–5 years or earlier, as required, with necessary notifications sent out to providers 6 months before expiration.

Non-Compliance and Reporting

If the delegated entity fails to comply with CMS credentialing requirements, it must immediately report any discrepancies or issues. Non-compliance may result in a revocation of the delegation agreement or the entity’s ability to handle credentialing for CMS-related programs.

Regular Updates and Training

It is essential for delegated entities to keep their staff trained and updated on any changes to CMS credentialing guidelines. This ensures that they can implement new standards and processes effectively.

Final Thought:

CMS credentialing is a critical process for healthcare providers to ensure eligibility for Medicare and Medicaid reimbursement. Staying compliant, submitting accurate documentation, and tracking credentialing timelines are essential to avoid delays and maintain ongoing eligibility. By following the proper steps and avoiding common mistakes, providers can ensure smooth participation in these vital federal and state-sponsored programs.

FAQs

Does CMS require physicians to be board-certified?

No, CMS does not require physicians to be board-certified, but board certification may be required for certain specialties or programs.

What does CMS consider a provider?

CMS considers a provider any healthcare professional or organization enrolled in Medicare or Medicaid, including physicians, nurse practitioners, and hospitals.

How to get a provider credentialed with Medicaid?

To credential a provider with Medicaid, submit an application through the state’s Medicaid provider enrollment portal, providing necessary documentation and meeting state-specific requirements.

How do I know if a provider is credentialed with Medicare?

You can verify if a provider is credentialed with Medicare by checking their enrollment status through the PECOS system or contacting the Medicare Administrative Contractor (MAC).

Which physicians are required to be board certified?

Physicians in certain specialties or those seeking participation in specific Medicare programs (e.g., managed care) may be required to be board-certified.

Does CMS require joint commission accreditation?

CMS does not require Joint Commission accreditation, but it is often required for hospitals and facilities seeking Medicare participation and reimbursement.