Insights
Why “getting in-network” is harder than you think, and what to do about it before denials and delayed cash show up.
You’ve probably heard: “You just need to get credentialed.” What no one tells you is that credentialing and contracting are two different processes. Getting either one wrong can delay or deny payments for months. Whether you are in Maryland, Texas, Washington, Oregon, Pennsylvania, Virginia, or elsewhere, getting in-network is not a form you fill out once. It is a payer-specific lifecycle with real revenue risk if nobody owns it end to end.
Credentialing verifies license, NPI, malpractice, DEA, CAQH, and background, and does not by itself make you active in the network. Contracting assigns a network effective date, provides a participation agreement, confirms what you will actually be paid, and enables authorizations and clean claim submission. You are not in-network until contracting is done and loaded. Claims get denied, authorizations get rejected, and practices lose months of revenue when that distinction is missed.
If nobody is tracking the full credentialing and contracting lifecycle, practices treat patients for months assuming they are in-network; claims deny for “provider not eligible”; payers cannot find TIN/NPI linkage; authorizations fail; fee schedules never get reviewed; and payment lands at out-of-network or default rates, or not at all. It is not just about getting listed. It is about getting paid.
Maryland Medicaid enrollment can require ePREP registration for both individual and group NPIs when billing under a group. CareFirst may use CAQH for intake while follow-up and contracting remain manual. Washington Apple Health is carved across multiple MCOs that each need their own process, and portal “credentialed” status can appear before a contract is executable. Texas TMHP enrollment does not auto-enroll Medicaid MCOs. Oregon CCO pathways and taxonomy linkage for PMHNPs billing under their own TIN create rendering-provider traps. Pennsylvania PROMISe IDs and MCO-specific contracting often diverge from CAQH approval timing. Virginia DMAS enrollment is only the first gate before separate MCO credentialing and contracting. Every state adds layers; these are examples, not an exhaustive map.
A workable lifecycle usually includes CAQH setup and attestation; state Medicaid enrollment when applicable; individual and group payer applications; weekly follow-up and documentation corrections; contracting and fee-schedule attention; effective-date verification and NPI linkage; EDI/ERA setup; live claim testing with payer-specific formatting; and ongoing re-attestation and revalidation tracking. You do not need a form filler. You need someone who owns claim readiness.
Most credentialing vendors “submit the application.” Most billing vendors “file the claims.” Too often neither owns effective-date tracking, fee-schedule review, POS/modifier compliance by payer, payer setup in the EHR, or test claims for routing and rejection. Practices can look credentialed for months and still not be activated to bill. That is why OneSource keeps credentialing integrated with full RCM rather than selling it as a detached commodity.
If you are launching, adding a clinician, expanding states, or seeing eligibility denials that do not match what a portal says, start with specialty, states, EHR, payers, and the friction you are seeing. Read the credentialing page for how OneSource models the work inside RCM, then tell us about your practice in writing.
The Insights library covers enrollment, configuration, denials, remittance, security, and practice growth in more depth.
