Provider Credentialing Checklist: Every Document and Detail Payers Ask For

For each individual provider

Identifiers

• Type 1 NPI, with the taxonomy matching the specialty to be billed
• Social Security number and date of birth
• CAQH ProView ID and current login (see the CAQH guide)
• Medicare PTAN and Medicaid ID, if already enrolled anywhere
• Any prior names, with documentation of the change

Licenses and certifications

• State professional license for each state of practice, number and expiration
• DEA registration and state controlled-substance registration, where applicable
• Board certification or board eligibility letter, with dates
• Specialty-specific certifications (for example CLIA for in-office testing, BLS/ACLS where the payer asks)
• Collaborative or supervising agreements where state law requires them for NPs or PAs

Education and training

• Diploma or transcript for the professional degree
• Internship, residency and fellowship certificates with start and end dates
• ECFMG certificate for international medical graduates

History

• Curriculum vitae in month-and-year format with no unexplained gaps over thirty days
• Hospital privileges, or a covering arrangement statement
• Malpractice claims history for the past ten years, with case summaries where applicable
• Explanations for any licensure action, sanction or exclusion, with supporting documents

Insurance

• Current professional liability face sheet showing carrier, limits, policy period and the provider’s name

Identity and immigration

• Government-issued photo ID
• Visa or work authorization documents where relevant

For the group or facility

• Type 2 NPI and taxonomy
• IRS letter (CP-575 or 147C) confirming the legal name and tax ID
• W-9 signed within the last year
• Articles of organization or incorporation, and any DBA filings
• Ownership and control disclosure for every owner, officer and managing employee
• Practice location details: physical address, phone, fax, hours, ADA accessibility, languages
• Bank letter or voided check for EFT
• Facility licenses where applicable (Article 28, OMH, OASAS, home care, lab)
• Liability insurance certificate for the entity
• Authorized official’s name, title and contact information

Details that cause rejections

• Addresses that differ between the NPI record, the IRS letter and the application
• A license or malpractice policy expiring during the expected processing window
• Specialty on the application that does not match the NPI taxonomy or board certification
• Signed forms older than the payer accepts (often sixty to ninety days)
• Disclosure questions answered “no” where verification will find a “yes”

Keep it current after approval

Credentialing is not a one-time event. Licenses, DEA registrations, malpractice policies and board certifications expire; CAQH wants attestation every 120 days; Medicare revalidates every five years and commercial plans re-credential every three. Track every expirable with a reminder someone owns. Our credentialing software does this per provider and per facility; our credentialing service does it for you.