Why This Checklist Matters
New healthcare practices face a critical challenge: you need to be fully enrolled with insurance payers before you can bill for services — but payer enrollment takes 60–120+ days.
Every day of delay in starting the enrollment process is a day of potential revenue loss after you open. Getting enrollment right from the start means having the documents organized, applications submitted correctly, and a follow-up process in place.
This checklist is designed for new practices, newly hired providers, and practices adding new payer relationships. Follow it in order — the early steps (NPI, CAQH, tax ID) are prerequisites for everything else.
Before You Start
Business and legal setup:
- •[ ] Legal entity formed (LLC, professional corporation, etc.)
- •[ ] EIN (Employer Identification Number) obtained from the IRS
- •[ ] Business bank account established
- •[ ] Practice address and contact information finalized
- •[ ] Practice name confirmed as it will appear on all enrollments
- •[ ] State business license or registration obtained (varies by state)
- •[ ] Government-issued photo ID (unexpired)
- •[ ] Medical school diploma or degree certificate
- •[ ] Residency and fellowship completion certificates/letters
- •[ ] Board certification certificate (if applicable)
- •[ ] Current CV with no unexplained gaps in employment
- •[ ] Reference letters from peers or supervisors (typically 2–3)
- •[ ] Medical license obtained in each state where services will be provided (note: licensing timelines vary — apply early)
- •[ ] DEA certificate obtained or in progress (if prescribing controlled substances)
- •[ ] Any state-specific controlled substance certificates
- •[ ] Verify license is in good standing with no restrictions
- •[ ] Professional liability insurance policy obtained
- •[ ] Certificate of insurance with current coverage dates and policy limits available
- •[ ] Understand whether your policy is occurrence-based or claims-made (payers often ask)
- •[ ] If claims-made policy: tail coverage details available
NPI Setup Checklist
National Provider Identifiers must be obtained before submitting any payer applications.
Individual NPI (Type 1):
- •[ ] Access NPPES at nppes.cms.hhs.gov
- •[ ] Apply for Type 1 NPI for each individual provider
- •[ ] Select the correct taxonomy code(s) for your specialty
- •[ ] Verify your address matches your intended practice location
- •[ ] Record your NPI number once issued (typically within 1–5 business days)
- •[ ] Apply for Type 2 NPI for the practice entity
- •[ ] Use the legal entity name and EIN
- •[ ] Select the correct taxonomy code(s) for the organization
- •[ ] Link the organization NPI to individual providers where required
- •[ ] Verify NPPES record reflects correct specialty taxonomy
- •[ ] Verify address matches what you will use on all enrollment applications
- •[ ] Verify entity name matches your legal entity name exactly
CAQH Setup Checklist
CAQH ProView is required for commercial payer enrollment with most major plans.
Initial CAQH setup:
- •[ ] Obtain CAQH Organization ID by registering at proview.caqh.org or by contacting a payer
- •[ ] Complete the Demographic section (name, address, specialty, contact information)
- •[ ] Complete the Education and Training section
- •[ ] Complete the Licensure section (all current licenses)
- •[ ] Complete the DEA and Controlled Substance section (if applicable)
- •[ ] Complete the Professional Liability section
- •[ ] Complete the Work History section (full history with no unexplained gaps)
- •[ ] Complete the Hospital Affiliations section
- •[ ] Complete the References section
- •[ ] Upload current medical license(s)
- •[ ] Upload current DEA certificate (if applicable)
- •[ ] Upload current board certification (if applicable)
- •[ ] Upload current malpractice certificate
- •[ ] Upload any other required specialty documents
- •[ ] Authorize all participating payers to access your profile
- •[ ] Complete attestation to confirm information is accurate and current
- •[ ] Document next attestation date (120 days from current attestation)
- •[ ] All required fields completed — no mandatory fields left blank
- •[ ] No inconsistencies between CAQH and NPPES records
- •[ ] Document expiration dates entered correctly
- •[ ] Attestation status showing as active
Medicare Enrollment Checklist
All providers billing Medicare must complete PECOS enrollment.
PECOS setup:
- •[ ] Create an Identity & Access Management (I&A) account at identity.cms.gov
- •[ ] Complete identity proofing
- •[ ] Access PECOS through I&A account
- •[ ] Complete Form CMS-855I (or electronic equivalent in PECOS) for each individual provider
- •[ ] Link individual NPI to the group/organization
- •[ ] Add practice location(s)
- •[ ] Submit reassignment of benefits to group entity
- •[ ] Document PTAN upon approval (typically 30–90 days)
- •[ ] Complete Form CMS-855B (or electronic equivalent) for the organization
- •[ ] Provide EIN, legal entity name, and authorized official information
- •[ ] Add all practice locations
- •[ ] Confirm surety bond if applicable (DMEPOS suppliers)
- •[ ] Enroll in Electronic Funds Transfer (EFT) for Medicare payments
- •[ ] Enroll in Electronic Remittance Advice (ERA)
- •[ ] Set revalidation reminder (revalidation typically required every 3–5 years)
Medicaid Enrollment Checklist
Medicaid enrollment is state-specific. Requirements vary by state.
- •[ ] Identify which state Medicaid program(s) you need to enroll with
- •[ ] Access each state's Medicaid provider enrollment portal or obtain paper application
- •[ ] Complete application for both individual provider and group entity as required
- •[ ] Determine if your state's Medicaid patients are predominantly in managed care organizations
- •[ ] If managed care: identify all Medicaid MCOs and apply separately with each
- •[ ] Upload required documents for each state application
- •[ ] Document Medicaid provider numbers upon approval
- •[ ] Track enrollment timeline (30–180 days depending on state)
- •[ ] Obtain full list of Medicaid MCOs operating in your state
- •[ ] Submit separate enrollment applications to each MCO
- •[ ] Track each MCO enrollment separately
Commercial Payer Enrollment Checklist
Before applying:
- •[ ] Identify target payers based on your patient population and local market
- •[ ] Verify panel status with each payer before applying — some plans close panels to new providers in certain specialties or geographic areas
- •[ ] Confirm whether specialty credentialing criteria apply to your specialty
- •[ ] Contact payer provider relations to obtain current enrollment application
- •[ ] Confirm whether payer uses CAQH (most do) or requires paper documentation
- •[ ] Ensure CAQH profile is attested before submitting application
- •[ ] Complete application for individual provider enrollment
- •[ ] Complete application for group/organization enrollment (usually required separately)
- •[ ] Submit all required supplemental documents
- •[ ] Record submission date and payer contact information
- •[ ] Set follow-up reminder for 3 weeks after submission
- •[ ] Primary payer(s) for your expected patient demographics
- •[ ] Medicare (through PECOS — see above)
- •[ ] Medicaid (state-specific — see above)
- •[ ] BlueCross BlueShield (local affiliate)
- •[ ] Aetna
- •[ ] Cigna
- •[ ] United Healthcare
- •[ ] Humana (especially for markets with high Medicare Advantage enrollment)
- •[ ] Any regional or specialty-specific plans relevant to your practice
After Submission
Ongoing follow-up:
- •[ ] Create a tracking spreadsheet for all payer applications (payer name, submission date, contact, application number, status, next follow-up date)
- •[ ] Follow up with each payer every 2–3 weeks
- •[ ] Respond to payer requests for additional information within 24–48 hours
- •[ ] Confirm effective dates in writing when approvals are received
- •[ ] Obtain and file copies of all contracts and participation agreements
- •[ ] Verify provider directory listings with each payer after enrollment
- •[ ] Configure practice management system with all payer IDs and effective dates
- •[ ] Set up EDI/clearinghouse connections for electronic claim submission
- •[ ] Verify EFT enrollment with each payer
- •[ ] Configure ERA for each payer
- •[ ] Complete a test claim submission to each payer before seeing patients
Recommended Timeline
| Timeline Before Opening | Action |
|---|---|
| 6+ months | Obtain NPI, begin state license applications |
| 5 months | Complete CAQH setup and attestation |
| 4–5 months | Submit Medicare PECOS application |
| 4–5 months | Submit Medicaid enrollment applications |
| 4 months | Submit commercial payer applications |
| 2–3 months | Begin systematic follow-up on all applications |
| 1 month | Confirm effective dates; complete billing system setup |
| Opening day | Verify all enrolled payers and effective dates |
This timeline assumes a straightforward credentialing scenario. Providers with complex backgrounds, multi-state practices, or specialized payer requirements should start earlier.
Frequently Asked Questions
What if a payer's panel is closed?
If a payer's panel is closed to new providers in your specialty or geographic area, you generally cannot enroll with them until the panel reopens. Contact the payer's provider relations team to confirm panel status and ask to be added to a notification list for when the panel opens. Some payers have exception processes for providers with unique specialties or serving underserved areas.
Do I need a separate enrollment for each location?
In many cases, yes. If a provider practices at multiple locations, each location may need to be listed on the enrollment with its own physical address. Some payers require a separate enrollment application per location; others allow multiple locations on one application. Confirm requirements with each payer.
How do I know which payers to prioritize?
Prioritize payers based on your expected patient demographics, your geographic market, and which insurance plans your potential patients are most likely to carry. Medicare and Medicaid are essential for most practices. For commercial payers, the major national carriers (BlueCross, Aetna, Cigna, United) cover a large portion of commercially insured patients in most markets. Local or regional plans may also be important depending on your area.
What is a credentialing effective date and why does it matter?
The effective date is the date from which a payer will accept claims from your newly enrolled provider. Claims submitted before the effective date will be denied. After enrollment is approved, confirm the exact effective date with the payer and do not bill insurance for services provided before that date without first understanding whether the payer allows retroactive billing.