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credentialing for medicare

A Detailed Guide To Conduct Credentialing For Medicare

In the United States, there are almost 65,748,297 people enrolled in the Medicare program. Medicare is a government insurance system that is offered to older people, around the age of 65 and more. As insurance is considered important in the U.S., healthcare facilities utilize many resources to keep the insurance payment collection efficient, we are talking about RCM. But today, we will discuss another aspect of healthcare facilities and that is credentialing for Medicare.

Credentialing is the process of verifying supplies used during medical treatment and the healthcare provider delivering the treatment. This process ensures a hospital is providing quality services to elders and secure their life. Let’s explore the process of credentialing for Medicare and how, as a healthcare provider, we can conduct this process.

Why To Perform Credentialing For Medicare?

hand of a person

This is the basic question that might arise in your head. As we described in the previous section, it proves your quality standards and informs the patients that you provide entrusted services. Have a look at its advantages in detail. 

Enhanced Patient Turnover

When patients know your health services and supplies fulfill quality criteria, they will be more likely to return to your healthcare facility. But if you don’t perform credentialing for Medicare, elderly patients won’t trust you with their health. As life is a precious gift and elderly people are more prone to diseases and disorders, they will never get any health treatment from an unverified hospital or clinic. Overall, conducting this process helps your patient base.

Quick Reimbursement

As Medicare is a government-based program, they will provide quick reimbursement to verified healthcare facilities. Those hospitals might have to wait for either verification or delayed response which hasn’t performed credentialing for Medicare. So this process not only increases your patient base but also enhances your financial well-being.

Trust Building

Credentialing is important not only for patients but also for insurance companies. Besides Medicare, there are other insurance companies as well that you have a contract with so proving your credibility can foster trust among them. Your contract might also be renewed and extended by conducting credentialing for Medicare, and your patient will spread word of mouth about your quality health services.

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Efficient Administration

Credentialing is not a one-time practice. You will have to conduct this process continuously after a certain period. Also, if you want to keep your healthcare supplies secure, make sure to conduct regular credentialing at least one time when you buy new stock. This way your supplies will meet safety standards, and even new equipment can be used without any worries. 

Besides all these benefits, with the help of supplies’ credentialing for Medicare, you will get rid of administrative activities. It helps reduce inventory management time and effort.

Medicare Offerings

As a healthcare provider having patients enrolled in a Medicare program, you will get many benefits from Medicare organizations. They offer valuable education programs, resources, and initiatives to enhance healthcare services. So if you utilize these assets, you can update your services, strengthening the financial condition. 

Credentialing Process

2 people discussing about credentialing for medicare process

As we are talking about credentialing for Medicare, after knowing its basics, the next step is to conduct credentialing. But how exactly does the process work? 

The process involves the verification of suppliers and physicians providing health treatments. One thing to note here is that in order to become a Medicare service provider, you have to credentialize your healthcare facility. This means the credentialing process should be conducted before applying for Medicare, as it is a government organization and they will prefer those hospitals that value their patients. Let’s see the process in detail.

  1. Application Submission

Starting from scratch, at first, you have to create a proper letter, known as an enrollment application. The details in the application should be related to healthcare facility and provider qualifications, rendered medical services, and other relevant information. Then, you have to submit this application to MAC (Medicare Administrative Contractor). Keep in mind to submit the application to your local MAC department.

  1. Verification 

Once they receive your application, the verification process begins. They will review your details, re-check, and make them verify the database and other local areas.

  1. Site Visit

In most of the cases, Medicare arranges a site visit and comes to your healthcare facility. The reason for this visit is that they make sure you meet their standard criteria. I.e if you have submitted an application for your supplies, then they will check your supplies carefully and interpret if you maintain quality. 

  1. PECOS Registration

For Medicare, PECOS stands for provider enrollment, chain, and ownership system. This is an online database portal used by Medicare to accept requests from providers. After the visit, you will need to access their portal and fill in the enrollment form.

  1. Screening

The MAC department already has many healthcare facilities and they have a vast database. When you submit your application, they review the data and see if you are excluded from applying for federal insurance programs. The reason could be anything, but legal and regulatory issues are most common among them. 

This process shows the importance of maintaining proper legal and regulatory standards in your healthcare facility. Any rules violence can cause problems for your facility in the future, as in this case, you won’t become eligible for credentialing for Medicare.

  1. CVO (Credentialing Verification Organization)

Even after the visit, many healthcare facilities must go through a credentialing verification organization. CVO is an individual department that verifies your credentials, qualifications, and affiliations. 

  1. Decision

This is the stage where your fate will be decided, whether you are approved or not. This process might take some time as they have to make sure a hundred things about a single facility and as you know hundreds of healthcare institutes apply for credentialing for Medicare. If luckily you have satisfied their criteria, then you will receive an approval notice from Medicare.

  1. Enrollment 

Once your healthcare facility is approved, you will be enrolled in the Medicare program, and you will be assigned a National Provider Identifier (NPI). You now can bill Medicare for the services you rendered to elderly patients.

Application To Apply For Credentialing

Once you know the benefits of credentialing for Medicare and the process, you might want to do a contract with them now. This can increase your patient number or if you have less patient base in your area, having Medicare insurance can boost the arrival of elderly people. So what is the process to apply for the Medicare program? 

First of all, you need to know that the first step is sending the application to Medicare. You don’t need to write an application by yourself, as the process is conducted electronically. You just have to access the PECOS form and fill in the necessary details to send your quote to Medicare. 

PECOS is basically an online enrollment system dedicated by the government to make the process efficient. The benefit of this system is that it eliminates the need for paperwork, reducing the chances of errors and omissions. It enables you to:

  • Enroll as a Medicare supplier or provider
  • Examine the data that is presently uploaded
  • Upload supporting documents
  • Sign your documents electronically and submit them online

But before sending the application, there are some codes allocated to each application type that you need to know.

  • CMS-855A: This is used to sign institutional providers, such as hospitals and skilled nursing institutions, up for Medicare for the first time and to renew their participation. 
  • CMS-855B: For group practices and other non-institutional providers, this application is utilized for initial enrollment as well as revalidation of Medicare enrollment.  
  • CMS-855I: Using this program, individual practitioners including doctors, nurse practitioners, and physician assistants can sign up for Medicare for the first time or renew their membership.  
  • 855R: To transfer Medicare benefits from one provider to another, utilize this application.  
  • CMS-855O: Ordering and confirming eligibility for Medicare home health services is done using this application.  
  • CMS-855S: The purpose of this application is to enroll new providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) in Medicare and to revalidate existing registration.  
  • CMS-20134: MDPP Suppliers may submit this application.

Besides, the following documents are also included with enrollment applications:

  • Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS-588)
  • Medicare Participating Physician or Supplier Agreement (Form CMS-460)


When you’ve finished filling the application out, print the paper after attaching your handwritten signature. It’s crucial to remember that when submitting a paper application, your signature must be hand-scrawled. 

Make sure to make a copy of the signed form that you may preserve for your records before mailing the application, your supporting papers, and the EFT Authorization Agreement form to your enrollment contractor. Your application will be complete and ready for processing thanks to this procedure.

Things To Consider

We hope you clearly understand the application essentials, from where you’ll access that, how to submit, and the next process. Now here are some considerations you must keep in mind if you want to get your quote approved in one go.

Write Proper Dates

Sometimes when you work on an application it might take longer than you think and you abandon that. If you continue that process on the next day, make sure to update the date and mention the accurate time i.e. the day when you submit the application.

Accurate Demographic Information

This is another crucial thing to take care of: you should add accurate demographic details in the application. Any misinformation can lead to application rejection and that might delay the process.

IRS-Approved Document

No matter if you’ve changed your facility name, in the Medicare form, you must write an accurate business name. Make sure to add the names that are listed in the IRS document and CP-575.

Include Valid Bank Info

You are also required to provide a bank account letter along with the application. So you must add a verified check and bank account information with the correct company name. Always re-check the info you enter.

Provide Active Contact Details

Another thing to keep in mind when submitting an application for credentialing for Medicare is that you provide your personal and active contact details. Don’t involve any third-party contact as it may hinder the process. Additionally, ensure active communication details in the form so that they can contact you whenever they want.

Use Blue Ink

This is a basic factor to consider when signing all types of forms. Use a blue-colored ink pen to sign the form. It will display your professionalism and make your credentialing process more likely to be successful. 

Mistakes To Avoid During The Credentialing Process

pen and credentialing paper

You must know some things to keep in mind before submitting the credentialing for Medicare application, there are certain mistakes that you should avoid. Medicare is a serious organization, they follow their rules strictly. So when you are in the credentialing process, here are some things to avoid if you want to be eligible for their program.

Wrong Credentials

When submitting your application, make sure to add accurate credentials, certificates, and qualifications. As we discussed earlier, this is a strict organization, Medicare can easily find out which information is misleading and which one is trustworthy. So keep in mind to provide the right data to prevent legal consequences.

Misleading Experience

Show your exact experience in the application. You can’t deceive Medicare by showing your extensive and non-existent experience. Also, this may lead to unethical practice and you can even end up facing legal trials.

Hiding Your Healthcare Facility Past

During credentialing for Medicare, you shouldn’t hide any of the legal restrictions or law violation cases of your healthcare facility in history. As they have extensive resources to find the historical performance of a facility, they will find out about your previous poor experience which may lead to quick rejection and even further investigation or cancellation of other programs.

Exact Patient Records

When showing your facility’s performance in terms of patients, including accurate information about patient numbers, information, and treatment records. Any misleading info may lead to legal penalties.

Unbundling And Upcoding

Unbundling refers to billing those medical treatments separately that have to be bundled, and Upcoding refers to billing higher-level services than provided. As you can see both terms are fraud-based activities, avoid them during credentialing for Medicare. Make sure to follow an accurate coding and billing process.

False Affiliations

Make sure the affiliations you show in your application are based on reality. Don’t mention false or misleading affiliations to avoid legal consequences. It can also result in your reputation loss.

Charging For Unnecessary Services

This point is more important to keep in mind during hospital billing. When you create a bill, never charge for the services or equipment that are unnecessary for the sake of your money. This could affect not only your patient’s health but also the federal organization, this way you are hurting nothing but your country. 

Ghost Billing

As the name indicates, ghost billing refers to billing patients for services that were never provided or received by the patient. It may also lead to severe consequences, so avoid this fraudulent activity.

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    Sharing Your Provider Number

    Your provider number is unique and critical, make sure you never share it with any third-party or unreliable entity. This may lead to the wrong usage of your number and scammers could get you in trouble after using it for the wrong purposes on your behalf.

    Wrong Practice Location

    To apply for credentialing for Medicare, make sure to provide an accurate location address. Misleading information leads to serious confusion during the process, it may even result in cancellation of your application. So re-check each and every single detail carefully.

    Identity Theft

    Keep your credentials and crucial information protected. Regularly review and update your serious information so that it doesn’t become easy to steal your identity and harm your reputation.

    Missing Documents

    Keep all the records of patients, their medical services, and other relevant documents. Any missing document may lead to suspicion, which could be a huge hurdle in the credentialing for Medicare.

    Caring For Seniors

    This was all you needed to know about credentialing for Medicare. Now if you want to upgrade your healthcare facility to Medicare, follow the steps we mentioned. Also, keep in mind the considerations to avoid any severe consequences and start treating older patients.

    Remember, during this whole process you should aim for addressing senior people’s health issues, not solely on getting the reimbursement from Medicare.

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