A simple breakdown of healthcare credentialing, Medicare vs Medicaid, CAQH management, and how provider enrollment works in the United States.
What is Credentialing?
Credentialing is the process of verifying that a healthcare provider is qualified, licensed, and eligible to treat patients and work with insurance companies. Without credentialing, providers cannot get paid by insurance plans.
Medicare vs Medicaid Credentialing vs Commercial
Medicare
Federal program (nationwide)
Mostly for 65+ patients
Single system (PECOS)
Standardized across all states
Medicaid
State-based program
Low-income individuals & families
Different rules per state
Multiple enrollments needed for multi-state providers
Commercial Insurance
Private Payers
Aetna
Cigna
UnitedHealthcare (UHC)
Blue Cross Blue Shield (BCBS)
Others...
What is CAQH?
CAQH is a centralized online system that stores a healthcare provider’s professional information. Insurance companies use it to verify credentials instead of requesting documents repeatedly.
Includes:
License details
Education & training
Work history
Certifications
Insurance documents
Credentialing Workflow
Collect provider documents
Create or update CAQH profile
Submit insurance applications
Verification by payers
Follow-ups & corrections
Approval & network activation
Ongoing re-credentialing
Simple Summary
Credentialing ensures healthcare providers are verified, approved, and able to receive insurance payments. It connects providers, insurance companies, and patients into one working system.