Work an application from intake to credentialed

For: Credentialing Coordinator · Time: 30–60 days end-to-end · Frequency: Most-frequent core workflow

Trigger

A new application was drafted (you, or your owner) for a provider × payer pair. Status is draft. You need to drive it to credentialed.

Outcome

The provider is in-network with the payer, effective date is recorded, the contract is filed, and the practice can bill claims to that payer.

Where

• Applications — list view, filterable by status / wave / payer
• Applications → Detail — per-application timeline, docs, transitions
• Kanban — drag-drop visual planning

Steps

1. Pre-flight. Open the application. Confirm: provider has NPI, taxonomy, CV/résumé attached, malpractice insurance certificate uploaded, all required state licenses are current, DEA (if applicable) is current.
2. Run PSV on the provider → playbook. Most payers want primary-source-verified license, board, and OIG/SAM exclusion checks within ~30 days of submission.
3. Transition status: draft → ready_to_submit. Right side of detail page → status dropdown. The platform validates required fields and won't let you transition if anything's missing.
4. Submit to the payer. Method depends on payer:
   • CAQH-attached payers (most commercial) — confirm CAQH profile is attested and re-attested within 120 days. Then trigger payer via their portal; the payer pulls from CAQH.
   • Direct-submission payers (Medicaid, some BC plans) — download the platform-generated application packet (PDF) from the detail page → upload via payer portal or fax.
   • Bulk-roster payers (Optum, some MA plans) — add provider to your next roster batch.
5. Transition: ready_to_submit → submitted. Record submission method + confirmation number in the notes.
6. Set follow-up. Application detail → Followups → New → 14 days out. Payer-specific tempos:
   • Commercial: 30–45 days first follow-up
   • Medicare: 60–90 days
   • Medicaid: 90–120 days (varies wildly by state)
7. Wait + follow up. Each follow-up: confirm payer received, ask for status, log response in notes. Transition to in_review once they confirm receipt.
8. Handle "pending info" requests → playbook. Status: in_review → pending_info → in_review.
9. Approval received. Transition: in_review → approved. Record effective date in the detail page.
10. Contract executed. Upload contract PDF, transition: approved → credentialed. Notify your RCM team — they can now bill this payer for this provider.

Watch-outs

• CAQH re-attestation deadlines kill applications silently. A CAQH attestation expires every 120 days. If yours expires while the payer is reviewing, they pull stale data and may deny. Set a recurring task to re-attest every 90 days, not 120.
• Effective date ≠ approval date. Some payers backdate to submission, some to approval, some to contract signature. Don't tell the practice they can bill until you've confirmed.
• Don't transition to credentialed without a contract on file. A verbal approval isn't a contract. The platform won't enforce this but YOUR RCM team will be furious when claims deny because there's no executed agreement.
• Status changes are audit-logged. Every transition is captured with timestamp and your user ID. Don't lie about dates "to make the report look better" — it's all there.
• Stale apps (>90d in in_review or pending_info) flag on the Agency Owner's compliance dashboard. If you're stuck, escalate; don't let it rot.

Related jobs

• Run PSV — required before submission for most payers
• Handle pending info — when the payer asks for more
• Renew a license — keeping the underlying credentials current

Something on this page doesn’t match what you see in the app? Email support@credentik.com and we’ll fix the guide.