Credentialing
Preparing and managing the payer-specific information, applications, and documentation healthcare organizations need to be recognized and set up correctly with the payers they work with.
What Credentialing Means
Credentialing is the process a payer uses to review and verify information about a healthcare organization, and where applicable its individual providers, before recognizing that organization or provider within its network or claims system. Depending on the payer, this can include reviewing licensure, ownership, accreditation status, liability coverage, and other organizational or provider information.
Accurate, complete, and current information matters because payers use it to decide whether an organization or provider is set up correctly in their own systems. That review is separate from whether the organization is otherwise operating properly.
Who We Support
Our credentialing support is built around DME and DMEPOS organizations, along with other healthcare businesses that need help preparing and managing payer-facing organizational information. This generally includes:
DME/DMEPOS suppliers working with Medicare, Medicaid, and commercial payers
Healthcare organizations completing payer-specific credentialing or provider-data applications
Businesses adding new locations, ownership changes, or additional payer relationships to existing credentialing records
If your organization’s situation falls outside this scope, tell us the specifics and we’ll let you know whether it’s something we’re able to help with.
Payer-Specific Preparation
Payers don’t share one application or one set of requirements. Each payer has its own forms, portals, documentation standards, and internal review process, and DME/DMEPOS organizations in particular can face payer-specific expectations around accreditation, supplier standards, and location-specific details.
Because requirements vary by payer, state, and organization type, preparing a credentialing submission generally means reviewing what a specific payer actually asks for, rather than applying one fixed checklist everywhere.
Our Credentialing Support
Depending on what your organization needs, our support may include:
Credentialing readiness review
Payer-specific application preparation
Organizational & provider information review
Documentation checklist & collection support
Application submission support
Payer follow-up on outstanding items
Status tracking
Coordinating responses to payer requests
Demographic & location update support
Recredentialing tracking
Network participation status monitoring
Maintaining credentialing records
How the Process Generally Works
This describes a general approach. The actual sequence, requirements, and timeline depend on the specific payer and organization, and some steps may be combined or handled differently depending on the payer.
Initial Review
We review the organization’s current information, payer goals, and available documentation.
Payer Requirements
We identify the applicable payer-specific requirements and the information that payer needs.
Application Preparation
We organize and prepare the applicable application and supporting documentation.
Submission & Follow-Up
We submit through the applicable payer process and track outstanding requests and status.
Status & Next Steps
We communicate payer updates and help identify remaining actions, effective dates, or next steps.
Documentation, Readiness & Ongoing Maintenance
Documentation requirements vary by payer, and by whether a request applies to the organization or to an individual practitioner. Some payers use CAQH to collect and maintain practitioner data; where a payer uses CAQH for credentialing or provider data, we can help organize the information needed for that process. CAQH is not used identically by every payer, and DME/DMEPOS organizational credentialing is often handled through payer-specific applications rather than CAQH.
Credentialing generally isn’t a one-time event. Many payers require periodic updates and recredentialing on a schedule set by that payer; many commercial payers that follow NCQA standards recredential on a cycle of roughly three years, though whether that applies, and the exact cycle, depends on the specific payer. Medicare applies its own revalidation schedule, addressed separately through our Medicare Enrollment service. Where applicable, we track recredentialing dates and support updates to locations, ownership, or other demographics as they change.
To begin, we typically need accurate organizational information and the documentation required for the applicable payer or credentialing process. The exact requirements depend on the organization and payer, but commonly fall into the groups shown here.
Organization
- Legal name, NPI, tax ID, ownership structure
- Business licenses, and accreditation documentation where applicable
- Liability insurance certificates
- W-9 and banking information for EFT, where applicable
Individual Practitioners, Where Applicable
- Licensure, certifications, and work history
- CAQH profile data, where the payer uses CAQH
Authorization
- Authorization to act on your behalf with the applicable payer, where required
Credentialing vs. Enrollment vs. Contracting
These terms are often used interchangeably, but they describe different parts of the process. Depending on the payer, some steps may be combined into a single application, or handled as clearly separate stages.
Credentialing
A payer’s review and verification of organizational and, where applicable, provider information, such as licensure, accreditation, ownership, and background, to determine whether the organization or provider meets that payer’s standards.
Enrollment
Formally applying to participate in a specific payer’s program, such as Medicare or a state Medicaid program, so claims can be submitted under that payer’s rules.
Contracting / Network Participation
Negotiating and signing a participation agreement with a commercial payer, which sets reimbursement rates and the terms governing the relationship, separately from credentialing itself.
Medway offers separate services for Medicare Enrollment and Payer Contracting. This page covers credentialing-related preparation and support; if your specific need is Medicare enrollment or contract negotiation, those pages address that directly.
What We Do / What the Payer Decides
What We Help With
- Organizing information
- Preparing applications
- Reviewing documentation for completeness
- Submitting through the applicable payer channel
- Tracking status
- Following up
- Coordinating responses to payer requests, within the scope you authorize
- Maintaining records
- Monitoring applicable renewal and recredentialing dates
What the Payer Determines
- Whether the organization or provider meets its requirements
- Whether the application is approved
- Whether network participation is available
- Contractual terms, where contracting is involved
- Effective dates the payer controls
- Final credentialing and network decisions
Common Questions
How long does credentialing take?
There’s no universal timeline. Processing depends on the payer, the type of application, how complete the submission is, current payer workload, and whether the payer requests additional information during review.
Can you credential us with a payer we’re not currently participating with?
We can help with the applicable credentialing and application process for that payer. Whether the organization is accepted, and how network participation is structured, is determined by the payer.
What happens if the payer requests additional information?
We review the request, confirm what’s being asked for, and help gather and submit the applicable response, within the scope you’ve authorized us to act on your behalf.
Do you handle recredentialing?
Where applicable, we track recredentialing dates and help maintain current documentation. Requirements and cycles vary by payer, so we work from each payer’s actual schedule rather than a single assumed timeline.
Is credentialing the same as payer contracting?
No. Credentialing is a payer’s review of organizational or provider information. Contracting is a separate step involving a signed participation agreement and reimbursement terms. Depending on the payer, the two may happen close together or as clearly separate processes; our Payer Contracting service addresses the contracting side specifically.
Do all DME suppliers need the same credentialing documents?
No. Documentation requirements vary by payer and by organization. What one commercial payer requires may differ from what another payer, or Medicare, requires.
Do you handle Medicare enrollment?
Medicare enrollment is a separate process from commercial payer credentialing, and it’s handled through our dedicated Medicare Enrollment service rather than this one. If Medicare enrollment is what you need, that page addresses it directly.
Credentialing Readiness Checklist
- Current organizational information and NPI on hand
- Business licenses and W-9 current
- Liability insurance certificate current
- Accreditation documentation ready, where required
- Ownership structure disclosed accurately and currently
- Recredentialing dates tracked from the start
What This Includes
- Payer-specific application preparation
- Submission support & follow-up
- Status tracking
- Recredentialing tracking, where applicable
- Network status monitoring
Discuss Your Credentialing Needs
Tell us which payer or payers, locations, and credentialing needs you’re working with, and we’ll help determine the appropriate next steps.