Step by Step Credentialing Guide for Healthcare Providers

Most new providers learn about credentialing the hard way after they've already started their practice and realize they can't bill insurance. Or they rush through it, make mistakes, and face denials and delays.

This guide walks you through the entire provider credentialing process step by step. You'll learn what credentialing actually is, why it matters, what documents you need, and how to navigate the process efficiently so you can start getting paid by insurance companies as quickly as possible.

What Is Provider Credentialing?

Before diving into the steps, it helps to understand what is credentialing in healthcare. Provider credentialing is the process of verifying your qualifications, training, licenses, and background to confirm you're eligible to provide healthcare services. It's how insurance companies ensure you meet their standards before they'll pay you for treating their members.

If you want a deeper breakdown of how credentialing compares to contracting, explore this guide on Credentialing vs Contracting in ABA Therapy

The Credentialing Process: A Step by Step Breakdown

Step 1: Gather All Required Information and Documents

Strong credentialing begins with complete and organized documentation. Missing items are the number one cause of delays.

Credentialing Checklist

• Education history (degrees, institutions, graduation dates)

• State licenses and DEA registration

• Board certifications (BACB for BCBAs, ABPP, ASHA, etc.)

• Work history with explanations for any employment gaps

• Malpractice insurance policy and claim history

• Three to five professional references

• Government-issued ID and demographic information

• Updated National Provider Identifier (NPI)

• Current CAQH profile (required for most payers)

• Payer-specific credentialing applications

Digitize everything and keep it organized. If you prefer a done-for-you solution, explore our therapy credentialing services for streamlined document management and tracking.

Many providers who use ABA credentialing services or a professional credentialing specialist avoid major delays because their documents stay organized and complete.

Step 2: Complete and Submit All Applications

Once everything is gathered, the next step is to complete the insurance applications. Every payer has different forms and formats, and even small inconsistencies can trigger rejections.

Best practices for completing applications:

• Use identical information across all payers

• Double-check license numbers, dates, and NPI details

• Provide a complete work history without gaps

• Combine documents into one well-organized submission packet

• Never leave fields blank; even non-applicable fields should be marked “n/a.”

If you’re working with an agency offering medical credentialing services, ABA credentialing, or a credentialing specialist, confirm they follow each payer’s unique rules.

Step 3: Primary Source Verification (PSV)

Once your application is submitted, the insurance payer conducts Primary Source Verification, a mandatory step where the information you provided is checked against sources.

This includes verification from:

• Universities or medical schools

• State licensing boards

• Certification bodies (such as BACB for ABA providers)

• Previous employers

• Professional references

PSV delays typically happen because an organization does not respond quickly. Be proactive. Contact schools, references, or employers if the payer requests follow-up.

Step 4: Background Checks and Sanction Screening

Credentialing is also a safety and compliance process. Payers conduct detailed background checks to ensure providers have clean professional records.

These checks include:

• National criminal background screening

• OIG exclusion list

• National Practitioner Data Bank (NPDB)

• State disciplinary actions

• Malpractice claim review

If any issues appear, the payer may request an explanation or additional documentation. Transparency is essential—explain the situation professionally and clearly.

Step 5: Credentialing Committee Review

After all verification is complete, your application will be reviewed by the Credentialing Committee. This panel evaluates:

• Compliance with payer criteria

• Ethical and professional standing

• Service needs within the network

• Documentation completeness

This review can take 2–8 weeks, depending on the payer, specialty, and state. Providers using ABA credentialing software often benefit from automated reminders and status tracking.

Step 6: Decision and Notification

When the review is complete, you receive one of three outcomes:

Approved

You are now officially credentialed. Some payers send contracts at this stage if they haven’t already. Once contracting is complete, you can begin billing immediately.

Pending Additional Information

You may be asked for clarity on past employment, updated documents, or revised CAQH details. Provide these quickly to avoid restarting the review cycle.

Denied

This is rare but possible. Denials may occur due to incomplete verification, missing documents, or network saturation. An appeal or re-application is sometimes allowed.

Experienced ABA credentialing specialists and ABA credentialing companies help providers negotiate contracts and correct errors at this stage.

If you want expert guidance on selecting the right partner, check out the list of Top 5 ABA Credentialing Companies

Step 7: Ongoing Maintenance and Recredentialing

Credentialing doesn’t end after approval. Providers must maintain their credentials and update information regularly.

This includes:

• Renewing licenses before expiration

• Refreshing CAQH every 120 days (required by most insurers)

• Keeping malpractice and demographic data current

• Reporting address or affiliation changes

• Completing recredentialing every 2–3 years

Missing one deadline can lead to lost network status, suspended payments, or forced reapplication.To assess whether your clinic’s process is strong enough, explore: Is Your ABA Clinic Credentialing Ready? Let's Discover

In-House Credentialing vs Credentialing Services

Aspect	In-House Credentialing	Outsourced Credentialing Services
Best For	Very small practices with limited payer panels	ABA, mental health, and multi-specialty groups
Scalability	Low — becomes difficult as locations or provider types grow	High — built to manage large volumes
Speed	Slower processing due to limited bandwidth	Faster turnaround with dedicated teams
Accuracy & Errors	Higher risk of errors as complexity increases	More accurate due to QA processes and automation
Staff Workload	Heavy administrative burden on internal staff	Reduced workload — external team handles most tasks
Technology & Tracking	Often limited	Strong software-driven tracking and automation
Cost Predictability	Variable and dependent on internal staffing	Predictable pricing and clear service rates

Common Credentialing Errors and How to Avoid Them

• Missing or expired documents → Keep all licenses and certificates in one organized, updated folder.

• Outdated CAQH information → Re-attest every 90 days and make sure your CAQH stays updated, especially if you hold licenses in more than one state. If you want a quick explainer on how CAQH helps manage multi-state licensing and keeps things consistent, you can read more about it here.

• Incorrect addresses or taxonomy codes → Double-check practice locations, NPI type, and taxonomy before submitting.

• Inconsistent work history → Ensure your resume and CAQH match with no unexplained gaps.

• Submitting incomplete applications → Have a credentialing specialist review all forms first.

• Not tracking applications → Follow up with payers every 10–14 days.

• No credentialing system → Use credentialing software to stay organized.

FAQ

1. What is checked during a credentialing process?

Credentialing reviews your education, licenses, work history, malpractice coverage, certifications, and CAQH details. Insurers use this to confirm you’re qualified, compliant, and eligible to join their network.

2. How to get credentialed with Medicare and Medicaid?

You apply through PECOS for Medicare and follow your state’s Medicaid enrollment portal. Submit complete documents, verify your NPI, update CAQH, and respond quickly to any requests from the payer.

3. What is the difference between licensing & credentialing?

Licensing gives you legal permission to practice in your state. Credentialing confirms your background, training, and qualifications so insurance payers can approve you to bill for covered services.

Conclusion

Credentialing is one of the most important—and often underestimated—administrative tasks in healthcare. Understanding what credentialing in healthcare involves and following a clear process helps avoid delays, protect compliance, and keep revenue coming in. When providers stay organized, keep CAQH updated, complete accurate payer applications, and review contracts carefully, medical credentialing becomes much smoother.

With the help of experienced medical credentialing services, the process is faster, cleaner, and more reliable. If your practice wants provider credentialing done right the first time, professional support can make a major difference.