Medicare and Medicaid Credentialing: What You Should Know

Jovin Richard
5 days ago
2 min read

At ACCORDPRO, we help practices navigate the credentialing process from start to finish. Here’s what you need to know about enrolling with Medicare and Medicaid, and how to avoid the common traps that cost providers both time and money.

Avoid Delays, Denials, and Compliance Risks with the Right Start

Credentialing with Medicare and Medicaid is a critical step for healthcare providers seeking to serve a wider patient base and ensure timely reimbursement. But the process can be complex, time-consuming, and riddled with technical pitfalls that can delay payments or jeopardize participation.

1. Understand the Difference Between Medicare and Medicaid

Medicare is federally managed and primarily serves individuals 65+ or with disabilities. Credentialing is done through the PECOS system and your local Medicare Administrative Contractor (MAC).

Medicaid, on the other hand, is state-run, and each state has its own portal, requirements, and timelines. Enrolling in Medicaid often involves more paperwork and background checks than Medicare.

Key Tip: Always review both federal and state-specific guidelines. What works for Medicare won’t always apply to your state’s Medicaid program.

2. Set Up Your NPPES and CAQH Profiles First

Before you begin credentialing, your NPI (via NPPES) and CAQH profile must be active and accurate. These systems serve as the foundation for all payer enrollment, including Medicare and Medicaid.

What to Do: Ensure that your legal name, business address, and tax ID match exactly across NPPES, CAQH, and IRS records. Inconsistencies are a leading cause of delays.

3. Enroll in PECOS for Medicare Participation

The PECOS portal is required for all Medicare applications. Providers must submit initial enrollment, group reassignment, and revalidation forms through this system.

What to Watch For:

Link your individual NPI to the group correctly
Upload all required documents (license, DEA, IRS letter, etc.)
Respond promptly to any MAC requests for additional information

ACCORDPRO handles Medicare PECOS enrollment end-to-end, ensuring proper setup and faster approval.

4. Follow Your State’s Medicaid Enrollment Process

Medicaid enrollment varies widely by state. Some states require fingerprinting, background checks, or notarized documents. Others offer online enrollment portals with multi-step verification.

What to Watch For:

Confirm if you need to enroll with MCOs (Managed Care Organizations) separately
Keep copies of all submissions and confirmation emails
Track application timelines to follow up as needed

ACCORDPRO manages Medicaid enrollment for multiple states and can help you understand regional nuances and avoid backlogs.

5. Stay on Top of Revalidation and Recredentialing

Medicare and Medicaid require revalidation every 3–5 years. Missing deadlines can result in deactivation, which means you stop getting paid—even if you're still seeing patients.

What to Do: Maintain a credentialing calendar and set alerts for revalidation dates. ACCORDPRO offers ongoing credentialing maintenance and automated reminders to protect your enrollment status.

Final Thoughts

Medicare and Medicaid credentialing are more than paperwork—they’re essential to ensuring uninterrupted care, timely reimbursements, and long-term growth for your practice.

With ACCORDPRO, you get a partner that understands the regulations, portals, and follow-through needed to keep your enrollments active and accurate.