Members Only | 07.23.25
Provider Enrollment in Government and Commercial Insurance
By Teddy Durgin
There has been much talk in NAMSS circles lately about the purpose of provider enrollment in both government and commercial insurance. And for good reason, in this rapidly evolving healthcare landscape, according to two association members we recently chatted with.
Yulanda Rini, director of provider enrollment for Pediatrix Medical Group, says, “The purpose of provider enrollment in both government and commercial insurance is to ensure that healthcare providers meet the required criteria of being properly credentialed, verified, and authorized to render services to covered beneficiaries and to be reimbursed for those services.”
Renee Baughman, senior credentialing, privileging, and enrollment specialist for UNM Medical Group Inc. concurs. She stressed the importance of registering healthcare providers to “ensure they meet specific standards to offer care to patients under their respective health insurance, enabling reimbursement, ensuring access to care, and for compliance/regulatory oversight.”
Both women were asked “what are the biggest differences between enrolling with a government payer (e.g., Medicare or Medicaid) versus a commercial insurance plan (e.g., Aetna, Cigna).” Rini says it is the enrollment requirements and processing timeframes. She states, “Government insurance plans like Medicare and Medicaid are federal and state-regulated and adhere to the Centers for Medicare & Medicaid Services (CMS) guidelines. Plan effective dates and enrollment timelines are more structured and consistent and less prone to delays, unlike the commercial plans — Aetna, Blue Cross Blue Shield, CIGNA, and United Healthcare — that maintain their own unique credentialing processes. They often utilize CAQH.”
Rini adds, “The credentialing processes and enrollment timelines differ significantly. Plan effective dates are not very consistent and are dependent on the processor working on the enrollment request. If there are delays in the enrollment process, such as backlogs or data entry errors, with commercial plans, escalations or corrections are less likely to be expedited.”
Baughman notes that governmental enrollment requires a comprehensive application that includes personal identifying information, professional history, practice location, and details regarding ownership and financial relationships. “The documentation places significant emphasis on compliance with federal and state regulations,” she says.
By contrast, commercial insurance enrollment requires standard credentialing documents such as medical licenses, board certifications, work history, and malpractice insurance. She states, “While some requirements may vary based on individual plans, the primary focus is often on verifying the provider's qualifications and operational practices.”
Government insurance requires providers to have and maintain a valid state license, National Provider Identifier (NPI), complete background checks and fingerprinting, and screening against the Office of Inspector General (OIG) Exclusion list and CMS Preclusion List. Rini says revalidation is typically required every five years for Medicare, while Medicaid revalidations may vary by state and can occur more frequently.
She adds, “Commercial insurance often follows the NCQA or URAC standards. Providers are required to maintain a valid state license and DEA registration. In addition, they must show proof of malpractice insurance, work history, education, board certifications, and hospital privileges, if applicable. This information typically is maintained in the provider’s CAQH profile, which many commercial payers use to streamline credentialing.”
Recredentialing is required every two to three years. However, timelines and documentation vary significantly depending on the payer.
It’s also important to note that there are different platforms or portals that are used for submitting applications. Medicare utilizes PECOS, while most Medicaid plans have their own state-specific portals. Some examples include: ePREP (Maryland), KMAP (Kansas), NCTracks (North Carolina), PAVE (California), ProviderOne (Washington), and TMHP (Texas).
Baughman remarks, “Every state has its own Medicaid portal, while Medicare utilizes a single portal accessible to all providers. Commercial payors also utilize their own applications and portals, while more and more are moving to CAQH.”
Our two interviewees were posed one final question: “How does delegated credentialing impact the provider enrollment process?” Baughman was quick to answer, stating, “Delegated credentialing simplifies the process for entities with a large number of providers by allowing them to use a roster to load providers into the commercial payer system without the need to send individual applications for each provider.”
Rini concluded, “Delegated credentialing can significantly impact the provider enrollment process in both positive and challenging ways. Some of the benefits include faster enrollment times, streamlined processes, and greater control and oversight to ensure data accuracy and compliance. Some of the challenges include increased administrative responsibility, frequent auditing and reporting, and not all payers offer or accept delegated credentialing, thus limiting its scope.”
Challenges aside, delegated credentialing involves a legal agreement outlining the duties and responsibilities of each party involved. When a healthcare organization authorizes another entity to handle the credentialing process on its behalf, the time and resources needed for provider enrollment can be greatly reduced. The result? Faster access to care and revenue generation.
In an increasingly complex healthcare environment, understanding the distinctions between government and commercial provider enrollment is essential for ensuring compliance, efficiency, and timely reimbursement. As MSPs and provider enrollment professionals continue to navigate evolving standards, technologies, and payer expectations, staying informed and adaptable remains key. Whether working with PECOS, CAQH, or delegated credentialing arrangements, your role is vital to supporting provider readiness and patient access to care.