Medical Billing

Navigating Medicare Credentialing Requirements: What You Need To Know

Medicare Credentialing Requirements

A number of Americans are enjoying the Medicare program, a state-sponsored plan for treating aged people. Physicians involved in Medicare plans should be credentialed in order to make sure that the best quality service is provided to patients. However, credentialing is a very complex step for healthcare providers or candidates who want to join the Medicare plan. State and federal compliance standards should be met to avoid any penalties and issues in the reimbursement cycle.

In this article, we will discuss the Medicare credentialing requirements, including different enrollment periods and key steps in undergoing this process.

What is Medicare Credentialing?

Medicare credentialing is basically the process of evaluating and judging the expertise of medical practitioners. Their training, educational background, experience, and licensing are confirmed by the respective bodies. Credentialing authorities contact the concerned departments to check the status of candidates’ submitted credentials. This process helps to choose the professional and skilled physicians for the Medicare program. Only the credentialed practitioners get reimbursements on time for the services they provide.


Understanding Medicare Enrollment Periods

Medicare offers several enrollment periods during which providers can apply for credentialing:

Initial enrollment period

This is the initial time that any provider can choose to participate in Medicare, and most often occurs when a provider begins to practice.

Special Enrollment Periods

Special enrollment periods are those that allow the providers to enroll themselves at any time they have a change of job or dwelling place.

Revalidation Periods

Providers have to reconfirm their participation in the given program every five years. Medicare will send a notification to providers when they will conduct the revalidation.

Key Steps In The Medicare Credentialing Process

1.   Obtain An NPI (National Provider Identifier)

The first initial step is to apply for a National Provider Identifier number, which is a ten-digit number given to every healthcare practitioner serving the United States. The NPI is used to code all providers in any administrative and financial dealings with health plans as mandated by the Health Insurance Portability and Accountability Act (HIPAA).

2.   Complete The CMS-855I Enrollment Application

Providers are also required to fill out CMS-855I, which is the application for enrollment in the Medicare program for an individual physician or NP Practitioner. The form has some sections that demand the identity of providers, practice details, and qualification information as well as the background information.

3.   Submit Supporting Documentation

This form is complemented by a number of documents that should be provided by the provider, such as licensure verification documentation, board certification documentation, copies of malpractice insurance policies, and educational documentation.

4.   Medicare Administrative Contractor (MAC) Review

After the application, accompanied by the necessary documents, is filed, it undergoes scrutiny by the Medicare Administrative Contractor (MAC). MACs are independent entities that provide Medicare with contractual enrollment services. 

5.   Site Visit

In some circumstances, Medicare may have to conduct site visits to the practice depending on the services being offered as indicated in the application so that Medicare can be certain that it meets Medicare standards.

6.   Approval And Issuance Of Medicare Billing Privileges

When Medicare approves the application, the provider gets a notice of approval and a Medicare provider number, which allows them to bill Medicare. This enables the healthcare provider to begin treatment and receive a receipt from Medicare for payment for services provided to those who are on Medicare.

Special Considerations For Different Provider Types

Different types of healthcare providers may have specific Medicare credentialing requirements:


Doctors must disclose substantial information concerning their education, training, and achievements in the form of board certification. They also have to present evidence of proper CME and active licenses in their respective state.

Non-Physician Practitioners

Nurse practitioners and other PAs are required to present proof of their education training and that they were licensed to practice. Physicians may also be required to show how the organization and new physician relationships best fit into collaborative or supervisory models.

Group Practices

Group practices to sign up an organization and get details of each and everyone offering services in the group. They must also confirm that all the above providers have accessed Medicare’s credentialing standards.

Facilities And Organizations

Requirements specific to the facility include facility accreditation, health and safety regulation, and liability insurance, among others, in facilities such as hospitals or clinics as well as laboratories or research facilities.

Guide To Improving Your Credentialing Experience

To navigate the Medicare credentialing process more effectively, consider the following tips:

Start Early

It is advisable to start the credentialing process as early as possible before starting practice in a new healthcare facility or organization. This will eliminate those matters which in turn will affect the provision of services offered to clients.

Stay Organized

It is most appropriate and advisable that appropriate records of all documents received and submitted be kept. Have a checklist that you could use to ensure that you have all the necessary documents enlisted in your application:

Double-Check Your Application

Make sure that all information that you fill in on the application form is correct and should contain all necessary information. Errors or gaps in documentation can mean a delay or rejection of a claimant’s request.

Utilize Resources

Some of the recommended resources you can use include the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). PECOS has enhanced the credentialing procedures through the Internet, whereby providers can submit and monitor their applications online.

Consider Professional Help

If the credentialing process seems daunting at this stage, then it’s advisable to hire a credentialing specialist or firm. Writing can be time-consuming, and especially when done by a layman, there are high chances of making mistakes or missing important details that are required for a successful completion and submission of the application. The services of a professional can, therefore, come in handy to offer guidance through the process of applying to prevent such mishaps.

Conclusion – Medicare Credentialing Requirements

Understanding Medicare and credentialing is not easy, but it is a worthy effort. If a provider is aware of all the requirements and processes involved in credentialing and if the provider has all the necessary documents well-arranged and compiled then a provider can easily go through this process. Revalidation guarantees that the providers are in coherence with government and Medicare standards, and they keep being issued reimbursements for their services with regular maintenance. Taking the time to enter and analyze all necessary data and taking the necessary precautions, all providers should be able to successfully navigate any credentialing maze and concentrate on quality services for patients. You can read our in depth blog about the flow chart for credentialing process.