We manage the complete credentialing and enrollment lifecycle from initial application to ongoing revalidation for physicians, specialists, group practices, hospitals, telehealth providers, and behavioral health organizations across the United States.
We enroll providers with insurance payers to secure faster approvals. We manage contracts, documentation, and communication to optimize reimbursement
We enroll providers in Medicare and Medicaid with full CMS compliance. We process applications, track approvals,
and activate billing
We manage CAQH credentialing by updating profiles and validating provider data. This reduces errors and accelerates approvals
We manage PECOS enrollment services for Medicare providers. We ensure accurate submission and prevent delays
We verify provider credentials directly from issuing authorities. This ensures compliance and reduces application denials
We register and manage NPIs to align provider data
across payer systems
We maintain accurate provider records to reduce inconsistencies and delay
We track deadlines and manage recredentialing to keep providers active in networks
We manage applications and renewals across multiple state licensing boards
We process DEA certifications and renewals to maintain prescribing authority
We manage CLIA certification for providers offering lab services
We manage hospital credentialing to secure provider privileges
We enroll providers in additional networks to increase patient access
We manage group provider enrollment for multi provider practices
We enroll providers for telehealth credentialing across multiple states
We accelerate onboarding for temporary providers
Centralized platform to manage provider data, profiles, and attestations
National Provider Identifier used across all payer systems
System used to enroll providers in Medicare
Process used to verify credentials directly from sources
Drug Enforcement Administration registration is required for prescribing controlled substances
Authorities that issue and validate provider licenses
Credentialing takes 30 to 120 days, depending on payer, specialty, and state
We manage provider licenses, NPI, DEA, malpractice insurance, education, and work history
In-house teams increase overhead, while outsourced credentialing reduces cost and improves efficiency
Clean submissions improve approval rates and reduce rework
We create and manage CAQH profiles, update provider data, and ensure timely attestations
We verify credentials using Primary Source Verification (PSV) directly from licensing boards and issuing authorities
We manage PECOS enrollment to ensure providers meet CMS requirements
We enroll providers with commercial insurance networks and submit accurate applications
We track applications, follow up with payers, and escalate delays to accelerate approvals
We analyze processes, identify gaps, and optimize workflows
We resolve credentialing denials and restore billing eligibility
We negotiate contracts to improve reimbursement
We accelerate approvals to reduce onboarding delays
We guide practices on scaling and optimizing credentialing operations
Aetna, UnitedHealthcare, Cigna, Humana, Anthem, Blue Cross Blue Shield (all state affiliates), Kaiser Permanente, Optum, Oscar Health
Medicare (Traditional Fee-for-Service), Medicare Advantage, Medicaid (all 50 states), Managed Medicaid MCOs, Tricare East, Tricare West, Tricare Overseas, Veterans Affairs (VA) networks
Magellan Health, Carelon Behavioral Health (formerly Beacon), ComPsych, Optum Behavioral Health, Cigna Evernorth
State-specific workers' compensation networks, No-Fault insurance (especially New York PIP), One Call, Coventry Workers' Comp
IPA enrollment, Third-Party Administrator credentialing, HMO and PPO network participation, and regional ACO enrollment.
| Category | Government Program Enrollment | Commercial Insurance Credentialing | Our Credentialing & Enrollment Solution |
|---|---|---|---|
| Programs Covered | Medicare, Medicaid, Tricare, VA | Aetna, UHC, BCBS, Cigna, Humana, Anthem | All Government And Commercial Networks, Plus MCOs And Workers' Comp |
| Standard Processing Time | 90 To 180 Days Due To Federal Workflows And Backlog | 60 To 120 Days, Depending On Payer Rules | 30 To 45 Days With Active Escalation |
| Compliance Requirements | CMS Mandates, State-Specific Medicaid Rules | Payer-Specific Portals, NCQA Alignment | Pre-submission Audit Against CMS And Payer Rules |
| Application Complexity | PECOS, Multi-Step Validation, Ownership Disclosures | CAQH-Driven, Payer Portal Submissions | Full PECOS, CAQH, And Payer Management Under One Workflow |
| Reimbursement Focus | Fixed Fee Schedules With Limited Flexibility | Negotiable Rates Based On Contracts And Specialty | We Optimize Contracts And Support Better Reimbursement Outcomes |
| Approval Rate | Around 80 To 85 Percent First Pass Success | Around 70 To 80 Percent First Pass Success | We Improve Approval Rates Up To 95 To 98 Percent With Clean Submissions And Proactive Follow-Ups |
Providers must submit a complete set of documents so payers can verify qualifications and approve network participation.
This typically includes
We verify every document through primary source verification, validate accuracy, and then process applications to avoid delays or rejections.
The credentialing timeline usually ranges from 30 to 120 days.
Government programs like Medicare can take closer to 90 to 120 days due to strict compliance checks. Commercial payers may take 60 to 90 days, depending on their internal review process.
Delays often happen when applications are incomplete or not tracked properly. We reduce timelines by actively tracking submissions and escalating with payers when needed.
CAQH acts as a centralized database where providers store their professional and practice information.
Payers pull data directly from CAQH during credentialing. If the profile is incomplete, outdated, or not attested, applications get delayed or rejected.
We manage CAQH profiles by updating data, validating information, and completing attestations on time so payer enrollment moves forward without issues.
PECOS is the system used to enroll providers in Medicare.
Without PECOS approval, providers cannot bill Medicare or receive reimbursement. The process includes identity verification, ownership details, and compliance checks under CMS guidelines.
We manage PECOS enrollment end-to-end, from application submission to approval tracking.
Primary source verification means we verify provider credentials directly from the original issuing authority.
For example
This step ensures accuracy and prevents fraud or errors. It is a mandatory part of insurance credentialing and directly impacts approval rates.
Credentialing is where we verify and validate provider qualifications
Enrollment is where we submit those verified details to payers and get the provider approved
Contracting is where reimbursement rates and terms are agreed with insurance networks
All three steps work together. Without credentialing, enrollment cannot happen. Without enrollment, billing cannot start.
We are not just medical billing providers; we are your dedicated partners in healthcare management services. Contact us to discover tailored solutions that transcend industry standards. Whether you’re a solo practitioner or a large healthcare facility, our expertise is designed to optimize your financial performance.
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740-766-6083
info@rcmxpert.com
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