Compliance & Credentialing resources
What to watch for in credentialing, enrollment, and eligibility verification -- the front-end work that determines whether claims ever get paid.
Start with what you are trying to do
Credentialing and enrollment are project work with a defined output, so the scope and the fee follow from the task rather than from your claim volume. You do not need a billing history to ask about any of these.
- A new entity that has never enrolled anywhere Type 2 NPI, I&A and authorized-official setup, the group’s CMS-855B through PECOS, CMS-588 for EFT, and tracking through the MAC’s development requests. The output is an enrolled, billable group; the fee is flat and fixed in advance. Medicare group enrollment
- Adding a provider to a group that already bills Per-provider enrollment and reassignment onto the existing group across Medicare, Medicaid and commercial payers, so a new hire can bill under the group instead of sitting idle. Provider enrollment service
- Joining another payer’s network Credentialing and network participation at an additional commercial or Medicaid payer. If what you actually need is a better rate rather than a new network, fee negotiation is a separate scope under payer contracting. Provider credentialing service
- A revalidation or re-enrollment deadline is coming up The ongoing half of the same enrollment scope: revalidations, terminations and changes of information tracked to their deadlines. Priced as ongoing management rather than per submission. Enrollment maintenance
- Checking coding and compliance before a payer does Independent chart-level coding audits with the sample size and the extrapolation limits stated up front, written findings, and a fixed fee agreed before the review starts. Coding audit service
Every Compliance & Credentialing guide, A to Z
Ambetter Provider Credentialing: How to Join by State
Ambetter has no national credentialing application. Eight verified state plan routes, CAQH and document rules from the 2026 manuals, and response windows.
Read the GuideCAQH ProView Is Now the CAQH Provider Data Portal (2026 Guide)
CAQH ProView is now the CAQH Provider Data Portal: how it works, the 120-day attestation cycle (180 days in Illinois), and what it does not replace.
Read the GuideCigna Provider Credentialing: How to Join the Network
How Cigna credentialing starts, the CAQH status it asks for, Evernorth's behavioral application routes and the dental path. Cites Cigna and Evernorth.
Read the GuideCMS-588 EFT Authorization: The Signer Rule and Everything Else
CMS-588 authorizes Medicare EFT — it is not enrollment. The same AO/DO on your CMS-855 must sign it. When you need one, bank-document rules, PECOS vs mail.
Read the GuideCMS-855B: How an Organization Enrolls in Medicare
Form CMS-855B enrolls clinics and group practices in Medicare. Who files it vs 855A/855I, why physician groups skip the $750 fee, and what MACs reject.
Read the GuideCMS-855I: What the Form Itself Requires, Section by Section
CMS-855I enrolls physicians and NPPs in Medicare and now carries every reassignment. Form selector vs 855B/855O, walkthrough, MAC timeframes, fee rules.
Read the GuideCMS-855R Discontinued: How Medicare Reassignment Works Now
CMS discontinued the CMS-855R on October 31, 2023. All reassignment actions now run through CMS-855I or PECOS. The post-2023 workflow, quoted from CMS.
Read the GuideEPSDT Medicaid Billing for Children: The Federal Rules
Medicaid EPSDT billing for pediatric well-child visits: the federal floor, why the state periodicity schedule governs, the EP modifier, VFC vaccine lines, and a dated state-by-state matrix.
Read the GuideGood Faith Estimate Requirements Under the No Surprises Act (2026)
Good Faith Estimates for uninsured and self-pay patients: the timing clocks, all eleven required elements, the open-ended co-provider enforcement discretion, and the $400 dispute threshold.
Read the GuideHIPAA Compliance in Medical Billing: Complete 2026 Guide for Practices and Vendors
HIPAA compliance for medical billing: BAA checklist, three rules (Privacy, Security, Breach Notification), minimum necessary standard, and how to vet a vendor.
Read the GuideInsurance Credentialing for Therapists: Who Credentials You at Each Payer
Who credentials therapists at Cigna, Aetna, UnitedHealthcare, Elevance and Medicare, what each publishes about timing, and what it does not.
Read the GuideMedical Billing Audit Checklist (2026): 47 Items to Review
47-item billing audit checklist: coding accuracy, documentation, denial trends, KPIs, compliance, and revenue leak detection — the first-engagement framework.
Read the GuideMedical Coding Audits: A Buyer's Guide (2026)
What a coding audit is: prospective vs retrospective, random vs focused, what OIG and CMS actually publish on sampling and monitoring, and how audit scope and pricing are structured.
Read the GuideMedicare Incident-To Billing Rules (2026)
Medicare incident-to rules as the regulation now reads: the nine conditions in 42 CFR 410.26, virtual direct supervision, the general-supervision exceptions, and a per-encounter eligibility check.
Read the GuideMedicare PTAN: What It Is, Who Issues It, and How to Find Yours
A PTAN is the Medicare-only number your MAC issues at enrollment approval. PTAN vs NPI vs MBI, recovering a lost PTAN, and the deactivation rules.
Read the GuideMedicare Revalidation: The Operational Playbook CMS Doesn't Publish in One Place
Find your Medicare revalidation due date, revalidate in PECOS, avoid deactivation. The 5-year cycle, 7-month rule and $750 CY2026 fee, all CMS-cited.
Read the GuideModifier 25: When to Use It (and When You Can't)
AMA CPT modifier 25 rules: when an E/M is significant and separately identifiable, the OIG audit triggers, audit-proof documentation, and common procedures.
Read the GuideModifier 59 vs X-Modifiers (XE, XS, XP, XU): The 2026 Picture
How modifier 59 and the X modifiers (XE, XS, XP, XU) work, when CMS requires the X modifiers, and the NCCI edit logic that drives bundling reversals.
Read the GuidePayer Credentialing Timeline and Cost (2026)
Credentialing, contracting, enrollment and effective dates are four separate gates. What each one controls, what the rules actually say, what it costs, and how to track it.
Read the GuidePECOS Enrollment: Step-by-Step Guide for Providers (2026)
PECOS enrollment step by step: which 855 form to file (855I or 855B — 855R discontinued), reassignment via the 855I, revalidation, and effective dates.
Read the GuidePlace of Service Codes: POS 11 vs POS 22 (and the Others That Matter)
POS 11 (office) vs POS 22 (on-campus outpatient hospital) and the reimbursement difference, plus POS 02/10 telehealth and patterns that produce POS denials.
Read the GuidePOS 02 vs POS 10: Telehealth Place of Service Codes Explained (2026)
POS 10 is telehealth in the patient's home (higher non-facility rate); POS 02 is telehealth elsewhere (lower facility rate). Rate table, payer rules and fixes.
Read the GuidePOS 13 in Medical Billing: Assisted Living Facility Code Explained (2026)
POS 13 = Assisted Living Facility, paid at the non-facility rate. Who bills it, E/M codes 99341-99350, POS 12/14/31/32/33 compared, and common denials.
Read the GuideProvider Enrollment Checklist (2026): 32 Items and When Each Applies
A 32-item provider enrollment checklist for Medicare, Medicaid and commercial payers — each item marked Required, If applicable, or Not required by payer.
Read the GuideType 2 NPI: Which Entities Need One and How NPPES Assigns It
Sole proprietor, single-member LLC, S-corp or group — the CMS-sourced entity table, the CP-575 legal-name match, and the free NPPES application, quoted.
Read the GuideFree Billing Audit · No obligation
Starting out, adding a provider, or due for revalidation?
Tell us the entity type, how many providers and which payers. Enrollment is quoted as flat project work, so there is no claims history for you to send — we will come back with the scope and the fee.
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Get a credentialing and enrollment quote
Provider enrollment is priced flat rather than as a percentage of collections, and the price is fixed in advance and quoted before any work starts. Tell us the entity and the payers; a billing history is not required.
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