CAQH, PECOS, NPPES & Payers: What Credentialing Actually Includes
When most providers hear the word credentialing, it sounds like a simple administrative step — fill out paperwork, submit applications, and wait for approval.
In reality, credentialing is an ongoing compliance system that requires monitoring, verification, and active management. Much of the work happens behind the scenes, and when it’s neglected, practices experience delayed approvals, billing interruptions, and even payer deactivation.
This week, we’re breaking down what credentialing actually includes — and why the hidden work matters.
CAQH: It’s Not “Set It and Forget It”
A CAQH profile is a living document. It must be continuously updated and reattested to remain valid.
Common issues that stall payer approvals include:
Expired liability insurance
Outdated licenses or DEA registrations
Old practice addresses
Missing hospital affiliations
Inconsistent demographic information
Payers cross-check CAQH data against submitted applications. Even small mismatches can trigger processing delays or requests for correction. Regular monitoring and reattestation are essential to keep providers active and billable.
PECOS Enrollment vs. Medicare Revalidation
Medicare enrollment is not permanent.
PECOS establishes participation, but providers and organizations must periodically complete revalidation to maintain billing privileges. Missing a revalidation deadline can result in Medicare deactivation — and reinstatement can take months, disrupting revenue and patient access.
Enrollment gets you in.
Revalidation keeps you in.
Tracking Medicare deadlines is one of the most critical — and most overlooked — parts of credentialing maintenance.
Primary Source Verification
Credentialing doesn’t rely solely on submitted documents. Payers independently verify credentials directly with issuing authorities.
This includes:
State licensure verification
DEA registration
Board certification
Education and training
Sanctions and exclusion checks
If records are inconsistent or incomplete, the approval process pauses until corrected. This verification stage is often the longest part of credentialing and requires active follow-up to prevent applications from sitting idle in payer queues.
Payer Applications, Follow-Ups & Portal Management
Submitting an application is only the beginning.
Each payer has unique requirements, forms, portals, and timelines. Applications must be tracked, followed up on consistently, corrected when needed, and pushed forward toward approval.
Without proactive follow-up, files can sit untouched for weeks or months.
Credentialing is not just paperwork — it’s ongoing project management.
Why This Hidden Work Matters
When credentialing maintenance is overlooked, practices risk:
Delayed effective dates
Denied or held claims
Provider billing interruptions
Medicare deactivation
Compliance exposure
Lost revenue
Credentialing is not a one-time task. It’s a lifecycle that protects a practice’s ability to operate and get paid.
Honored Healthcare Systems manages credentialing from start to finish — CAQH oversight, PECOS monitoring, payer submissions, follow-ups, and demographic maintenance — so providers stay in-network and practices stay operational.
