SolutionsCredentialing
Credentialing
Keeping providers enrolled, current, and able to be reimbursed.
Why this one
costs you money.
Credentialing does not generate revenue, but it gates it absolutely. A provider who is not enrolled with a payer cannot be reimbursed by that payer — however accurate the coding and however clean the claim.
The work is administrative and almost entirely about time: applications that take months, revalidations that arrive on a schedule, and records that stop being true the moment a practice address or tax ID changes.
What this discipline
actually involves.
- Payer enrolment tracked from application through to approval.
- Re-credentialing and expirations monitored before they lapse.
- CAQH and payer records kept consistent with current practice details.
- New providers progressed in parallel with onboarding, not after it.
- Enrolment status visible, so nobody is scheduled against a payer they cannot bill.
The method.
Enrol
Applications are prepared and submitted per payer, then tracked through to an approval number rather than to submission. An application sitting incomplete on a payer’s desk is not progress.
Maintain records
CAQH and payer-held records are kept consistent with current practice details. Payers pay against what they hold on file, not against what is true.
Monitor expiries
Licences, DEA registrations, malpractice cover and re-credentialing dates are tracked ahead of their deadlines rather than on them.
Report status
Enrolment status per provider per payer is visible, so scheduling never books a provider against a payer they cannot bill.
What you receive
- Enrolment status by provider and by payer.
- Expiries and revalidation dates tracked ahead of time.
- CAQH and payer records maintained.
- New-provider enrolment started in parallel with onboarding.
The failure modes.
A lapsed credential
A provider whose credential has expired cannot be reimbursed — however good the billing is.
Enrolment as an afterthought
Starting enrolment after a provider joins gates their revenue for months.
Stale payer records
An old address or tax ID on file is enough to stop payment.
What clients say.
Credentialing requires a lot of follow-up and attention to detail. Exact Core brought much-needed organization to the process and helped us stay on top of enrollment and approval requirements.
Our organization has several specialties with different payer requirements and workflows. Exact Core has been able to bring consistency to the revenue cycle while still understanding the differences between each area of the practice.
About credentialing.
How long does payer enrolment take?
It varies by payer and by state, and the range is wide enough that any single figure would be misleading. What can be controlled is that the application is complete on first submission and then followed up — incomplete applications are the most common reason timelines stretch.
When should credentialing start for a new provider?
As soon as the start date is known. Enrolment runs on the payer’s clock, so beginning after a provider has joined gates their billable revenue for as long as the process takes.
What happens if a credential lapses?
Claims for that provider stop being payable, usually without warning, and the balances build in AR until somebody traces the cause. Expiry monitoring exists so that this never becomes the explanation.
Do you handle re-credentialing as well as initial enrolment?
Yes. Re-credentialing is the more common failure point, because initial enrolment has somebody waiting on it and revalidation does not.
The other five disciplines
Revenue leaks between them, which is why they are managed as one cycle.
Medical billingMedical codingDenial managementAR ManagementEligibility verificationPatient supportFront office management
How is credentialing
performing for you?
A revenue assessment reviews all eight disciplines end to end and shows you where the reimbursement is going.