Everything You Need to Know About Credentialing Companies in New York

When a medical professional wants to start practicing in New York or anywhere else in the United States, the first step is getting enrolled with the insurance payers commonly used by patients in that area. This process, known as credentialing, requires payers and hospitals to verify the provider’s qualifications, including education, training, state licensure, work history, board certifications, malpractice records, and other critical details. Proper credentialing ensures providers can accept insurance, bill accurately, and begin treating patients without delays.

Successful credentialing:

• Allows the provider to be recognized by commercial payers, Medicare, and Medicaid.
• Enables billing and reimbursement for insured patients.
• Reduces claim denials, gaps in reimbursement, and administrative friction.
• Demonstrates compliance and reduces risk from audits or payer investigations.

For practices, clinics, solor practitioners and hosptials in New York, credentialing also means following state-specific enrollment steps and safeguards, so working with a vendor familiar with NY systems and regulators is particularly valuable.

New York–specific steps and regulators you need to know

Several federal and New York state systems/regulatory bodies are key players in provider enrollment and credentialing.

1. NPI & CAQH:

Almost every provider must have an NPI and typically maintain a CAQH ProView (or equivalent) record for payer submissions. (National requirement; CAQH is the commonly used clearinghouse.)

2. eMedNY (New York State Medicaid):

New York’s Medicaid program (eMedNY) handles Medicaid provider enrollment, revalidation, and many provider type–specific rules. The eMedNY Provider Enrollment pages explain required documents and the step-by-step enrollment guide.

Reference: emedny.org

3. Medicare / PECOS:

Medicare enrollment is processed through CMS systems such as PECOS or the CMS enrollment forms (CMS-855 series). Many credentialing companies prepare and submit Medicare applications on behalf of providers.

Reference: CMS

4. OMIG (Office of the Medicaid Inspector General):

OMIG monitors Medicaid integrity in New York and publishes guidance, recovery audits, and fraud alerts. OMIG considerations (exclusions, OIG checks) are critical for safe enrollment.

Reference: omig.ny.gov

(If you participate in managed care plans, each plan will have its own credentialing/contracting process on top of state/federal enrollment.)

What a credentialing company does — services and deliverables

A professional credentialing firm handles all or part of the credentialing and enrollment workflow. Typical services include:

1. Document collection & organization:

Compile CV, licenses, board certificates, malpractice/loss runs, DEA (if applicable), state controlled-substance registrations, hospital privileges, and more.

2. Primary Source Verification (PSV):

Verify licenses, education, board certification, and other credentials directly with primary sources.

3. Payer applications & submissions:

Complete and submit applications to commercial payers, Medicare (PECOS/CMS forms), and Medicaid (eMedNY).

4. CAQH profile setup and updates:

Create/maintain CAQH ProView entries and ensure attestations are current.

5. Follow-ups & appeals:

Manage payer requests, correct deficiencies, and accelerate review with targeted follow-ups.

6. Recredentialing & ongoing monitoring:

Track revalidation deadlines, license expirations, sanctions, and perform periodic monitoring.

7. Contracting support:

Negotiate and route payer contracts (some firms also handle contract review/negotiation).

8. Compliance checks:

OIG/GSA/SAM exclusion checks and other regulatory verifications.

A good vendor will give a project timeline, assign a dedicated account representative, and provide a status dashboard or regular updates.

Documents & checklist — what to gather before you start

Having the right documents ready shortens the process dramatically. Here’s a practical checklist you can use to prep each provider:

• Current CV or professional resume (detailed work history with dates)
• Copy of medical/clinical license (state) and license verification numbers
• NPI number
• DEA certificate (if applicable) and state controlled-substance registration
• Board certification (if applicable)
• Current malpractice insurance declarations page and loss runs (usually 3–5 years)
• Photo ID (driver’s license/passport)
• Social Security Number / Tax ID info (for Medicare/Medicaid paperwork)
• CAQH logins (or willingness to create a CAQH profile)
• Hospital privileges or privileging letters (if required by payers)
• W-9 (for billing/payee setup)
• Facility paperwork for group practices: Articles of Organization / Business license, EIN, lease agreement (sometimes required)
• Any sanctions, investigations, or malpractice claims history (disclose proactively)

Most credentialing firms will provide a checklist and a secure portal to upload these documents.

(Use this checklist when you engage a vendor — missing items are the most common cause of delay.)

Typical timelines & costs (realistic expectations)

Timelines (typical, variable by payer): Timely filing limit for insurance claims submission varies from state to state.

• Commercial payer credentialing: 60–120 days from submission to approval (some plans are faster; some slower).
• Medicare enrollment (PECOS/CMS): 60–120+ days, depending on completeness and whether additional documentation is requested. Ref: CMS
• Medicaid (eMedNY) initial enrollment or revalidation: 60–120 days; complex enrollments or corrections can take longer. Ref: emedny.org

Costs (estimates — market varies widely):

• One-time initial credentialing per provider: $250–$800 (range depends on scope: single payer vs. full-service across Medicare/Medicaid/commercial).
• Monthly monitoring/recredentialing services: $25–$75 per provider per month.
• Expedited or concierge services cost more — often a one-time premium fee.

If speed and compliance are critical, budget for expedited service or a hands-on managed approach that includes regular follow-ups.

How to choose a credentialing company — 9 questions to ask

When evaluating vendors, get clear answers to these questions:

1. Do you have experience with New York Medicaid (eMedNY) and OMIG requirements? (ask for examples) emedny.org
2. Do you handle Medicare enrollment via PECOS/CMS or do you subcontract it? CMS
3. What’s your average turnaround time for full credentialing across commercial payers, Medicare, and Medicaid?
4. Do you provide primary source verification (PSV) and ongoing monitoring?
5. Who will be our dedicated contact and what reporting/dashboard access will we have?
6. What is included in your fees and what is extra (e.g., reattachments, chasing down payers)?
7. How do you protect PHI and what security/compliance certifications do you have?
8. Can you provide client references (ideally NY practices of similar size)?
9. Do you offer bundled services (credentialing + contracting + enrollment + CAQH maintenance)?

Pick a vendor that demonstrates New York law familiarity (eMedNY/OMIG) and gives transparent SLAs.

Common pitfalls — and how credentialing companies help avoid them

• Incomplete applications: missing documents are the single largest cause of delays. Vendors that pre-check files reduce rework.
• CAQH lapses / attestation expirations: automated reminders and vendor-managed attestations help prevent denials.
• Not monitoring revalidations: missed revalidation leads to suspended payments. Ongoing monitoring services reduce this risk.
• Failure to perform exclusion checks: OMIG/OIG exclusions can lead to serious fines; reputable vendors run recurring exclusion checks. omig.ny.gov

Frequently Asked Questions