When a practice asks “how long until Dr. Smith can bill?”, the right answer is a range per payer, plus a list of what could make it longer. You will find many confident single numbers online. They are estimates. What you can be precise about is what the timeline is made of.
What the timeline is made of
- Preparation: collecting the provider’s information and documents, updating and attesting CAQH, getting access and signatures. This is the part you control most.
- Submission and intake: the payer checks the application is complete. Incomplete applications go back to you.
- Verification and review: the payer or its CVO verifies credentials and, for commercial plans, a credentialing committee makes a decision.
- Contracting and loading: for commercial plans, a contract must be in place and the provider loaded into the payer’s systems before claims pay in-network.
- Effective date: the date from which the payer will pay. It may be before, on or after the approval date, depending on the payer.
What official sources say about delays
CMS has published useful detail on what slows Medicare enrollment. In a 2017 presentation on avoiding processing delays, CMS stated that:
- 30 to 35 percent of applications result in delays;
- incomplete applications are typically delayed 30 to 45 days;
- development requests (requests for more information) exceeded 50 percent for paper applications and were about 25 percent for web applications;
- providers have 30 days to respond to a development request, after which the contractor may reject the application.
The lesson carries over to every payer: complete, consistent applications submitted electronically move faster, and fast answers to payer questions keep them moving.
The parts you control
- Collect every document before you start, using a standard onboarding checklist
- Make CAQH complete and current, and re-attest on time (CAQH asks for re-attestation every 120 days, per its FAQs)
- Make names, addresses, NPIs and tax IDs match exactly across CAQH, PECOS, NPPES and the application
- Submit electronically where the payer allows it
- Follow up on a schedule, and answer requests the same week
- Start recredentialing and revalidation months before the due date
- Record each payer’s actual turnaround so your next estimate is based on your own data
The parts you do not control
- The payer’s backlog and committee schedule.
- Whether a commercial network is accepting new providers in that specialty and area.
- Contract negotiation timelines.
- Off-cycle revalidation drives by Medicare or a state Medicaid program, which can add load across the board.
Setting expectations with a practice
Give a range per payer based on your own history, explain what could extend it, and agree what the practice will do in the meantime, for example scheduling patients of other payers first. Show progress as it happens instead of waiting for the practice to ask; a client portal does this without extra emails.
Tracking timelines in Credentik
Credentik records when each application entered each status, so you can see how long an application has been in review, find stalled work in the work queue, and report turnaround by payer from your own data. See payer enrollment tracking.