What No One Tells You About Credentialing (Until it's too late)

Why “Getting In-Network” Is Harder Than You Think — and What to Do About It

You’ve probably heard:

“You just need to get credentialed.”

But what no one tells you is that credentialing and contracting are two different processes — and getting either one wrong can delay or deny your payments for months.

Whether you're in Maryland, Texas, Washington, Oregon, Pennsylvania, Virginia, or anywhere else, getting in-network isn’t a form you fill out once. It’s a complicated, payer-specific lifecycle with major revenue risks if you don’t manage it end-to-end.

🧭 Credentialing ≠ Contracting: Why It Matters

Many providers think that once they’re credentialed, they’re good to go. But that’s not how it works.

➤ Credentialing

Verifies your license, NPI, malpractice, DEA, CAQH, and background

Does not make you active in the network

Often handled by third-party teams without direct contracting authority

➤ Contracting

Assigns you a network effective date

Provides a participation agreement

Confirms what you’ll actually be paid

Enables you to get authorizations and submit clean claims

You’re not in-network until contracting is done and loaded. We’ve seen claims denied, authorizations rejected, and providers lose months of revenue simply because they didn’t realize this.

🛑 What Goes Wrong Without a Plan

If no one is tracking the full credentialing + contracting lifecycle, here’s what happens:

• You treat patients for months assuming you’re in-network

• Claims get denied for “provider not eligible”

• Payers can't find your TIN/NPI linkage

• Authorizations don’t go through

• Fee schedules never get reviewed

• You get paid at out-of-network or default rates — or not at all

It’s not just about getting listed. It’s about getting paid.

📍 State-Specific Credentialing & Contracting Pitfalls

Here are just a few examples of what we routinely see when helping providers navigate credentialing and contracting across different states. Every payer has quirks — and each state adds layers of complexity.

Maryland

Maryland Medicaid enrollment requires registration in ePREP, including both individual and group NPIs (if billing under a group). Claims will reject if either piece is missing.

CareFirst BlueCross BlueShield uses CAQH for credentialing intake, but follow-up and contracting are handled manually via phone, email, and internal review — with no reliable portal status tracking.

Many commercial payers process credentialing and contracting through different departments with no automatic status updates, leading to hidden delays if not followed closely.

Washington

Apple Health (Medicaid) is carved out across multiple MCOs (Molina, CHPW, Amerigroup, UHC), each requiring a separate credentialing application.

Providers often show as “credentialed” in a portal before their contract is fully executed, leaving them unable to bill.

Carelon (formerly Beacon) and Optum require additional follow-up to confirm participation in the correct behavioral health networks.

Texas

TMHP enrollment is required for Medicaid but does not auto-enroll you in the Medicaid Managed Care Organizations (MCOs). Each MCO requires its own credentialing and contracting process.

Secondary billing access is often blocked if the TIN or NPI isn’t properly enrolled at the state level.

Superior, Amerigroup, Aetna Better Health, and others all use different systems and timelines — some managed through CAQH, others via direct submission or third-party portals.

Oregon

Medicaid credentialing is managed through Oregon Health Plan (OHP) and its regional CCOs, each of which may have separate onboarding requirements.

Providence, Moda, and PacificSource often require persistent follow-up — and credentialing status is rarely reflected in any online portal.

PMHNPs billing under their own TIN must ensure correct taxonomy codes and linkages or face rejections for invalid rendering providers.

Pennsylvania

PROMISe ID is required for Medicaid but each MCO (like UPMC, Keystone First, Health Partners) handles its own credentialing and contracting.

Providers often receive CAQH-based credentialing approval but get stuck waiting on manual contracting communication.

Highmark and IBX have tight timing windows — if your CAQH attestation isn’t current when they review, your application stalls.

Virginia

DMAS enrollment is required first, but most MCOs (Anthem, Optima, Aetna Better Health) require separate credentialing and contracting after the state approval.

Pediatric services, autism-related services, and telehealth often require add-on enrollment tracks.

Application stalls are common due to CAQH mismatches, incorrect NPPES records, or unsupported address/TIN combinations.

🔍 Every State Is Different — And We Do the Research

These are just a few examples. Before we credential any provider, we:

• Research all Medicaid pathways, commercial payers, and carve-outs

• Identify which portals, forms, and departments manage each phase

• Track credentialing, contracting, and effective dates in real time

You’ll never get a one-size-fits-all plan from us — because that’s how practices get stuck.

🧾 The Real Credentialing Lifecycle (Not the One You Read Online)

1. CAQH setup + attestation

2. State Medicaid enrollment (if applicable)

3. Individual and group payer applications

4. Weekly follow-up, rework, and documentation corrections

5. Contracting and fee schedule negotiation

6. Effective date verification and NPI linkage

7. EDI/ERA setup

8. Live claim testing + payer-specific claim formatting

9. Ongoing re-attestation and revalidation tracking

You don’t need a form filler — you need a revenue strategist.

🧠 Why Most Billing Vendors Get This Wrong

Most credentialing vendors just “submit the application.”

Most billing vendors just “file the claims.”

But neither one owns:

• Effective date tracking

• Fee schedule review

• POS/modifier compliance by payer

• Payer setup in your EHR

• Testing claims for routing and rejections

We’ve helped clients who were credentialed for months but were never activated to bill. We’ve recovered thousands in unpaid claims after finding credentialing errors no one caught.

🔁 Why We Only Do Credentialing As Part of Full RCM or Consulting

At OneSource RCM, we only offer credentialing when we’re managing the full revenue system — either through RCM or strategic consulting. That’s because:

Credentialing touches billing, authorizations, patient communications, and more

We verify every NPI, POS, modifier, and routing detail before a single claim is submitted

We don’t wait for denials to “see what went wrong” — we set it up right from day one

✅ Want Credentialing That Doesn’t Cost You Thousands?

Whether you're in Oregon, Virginia, Pennsylvania, or anywhere else, we do our homework before your first claim ever goes out.

🧭 Final Note: Every State Is Different

We highlighted just a few examples in this post — but every payer network works differently in every state. Before we credential any client, we research your specific state, your specialty, and your payers to develop a customized credentialing game plan that works.

This isn’t guesswork. This is strategy.