Credentialing & Contracting Intake

1Who is this intake for?

You are a solo practitioner enrolling yourself with payers.

5What services are you interested in?

Pick everything you want handled. The form asks for the complete file regardless of selection - everything you provide now is information we never have to come back and ask you for later, and it shortens every future service.

CAQH profile, new build: $500 per provider
Built from your file, every section completed, documents uploaded, attested. CAQH profile, update and attestation: $250 per provider
You already have a profile. We complete and correct it, refresh documents, and attest. Medicare enrollment: $500 per provider
PECOS (855I, 855R or 855B as applicable) and EFT, followed through to approval. Half at engagement, half at approval. Medicaid enrollment: $500 per provider, per state
Your state program through its portal, followed through to approval. Managed-care plans are commercial applications below. Half at engagement, half at approval. Availity setup: $250 per provider
Registration and payer-portal linkage on Availity, which most commercial plans use. Commercial payer applications: $200 per application, per provider
Each commercial plan, Medicaid managed-care plan or Medicare Advantage plan you pick in section 5. Half at engagement, half at approval. Primary source verification bundle: pricing on request
We confirm your license, education, and certifications directly with the issuing sources (licensing boards, schools, certification boards) - the verification standard payers and hospitals require - and provide documented evidence. Scope and pricing depend on the sources involved (some registrars and boards charge their own fees), so this is quoted individually before any work begins. Group onboarding: $500 one-time
Group entity setup: Type 2 NPI linkage, group payer records, roster management. Ongoing maintenance: $100 per provider / quarter
CAQH re-attestations, expirables tracking, revalidations, payer follow-ups - and for groups, roster reviews to catch provider additions and departures. Contract rate negotiation: $500 per successfully negotiated contract
We pull your proposed or current fee schedule, run a full analysis and review of your top codes against Medicare benchmarks, and negotiate for stronger rates (especially specialist codes). The fee applies only when a negotiation succeeds. Fingerprinting coordination: $75 per occurrence
Some enrollments (certain Medicaid and state programs) require fingerprints. We identify the requirement, book the correct IdentoGO Live Scan appointment with the right service code, and track results through to the agency. IdentoGO's own collection fee (~$50–80) is paid at the appointment. Billed only when an enrollment actually requires it. NPI procurement: $100 per NPI
Type 1 (individual) or Type 2 (organization) NPI application prepared and filed via NPPES, with the taxonomy code set correctly - payers cross-check it on every application later. For new practitioners and newly forming practices. Tax ID (EIN) procurement: $150 one-time
We prepare and file your IRS SS-4 as third-party designee and deliver your EIN - for new practices that don't have a Tax ID yet.

DME suppliers
Medicare DMEPOS enrollment, revalidation, added locations and DME contracting have their own form: the DME supplier intake.

Something else: special services upon request
Not everything we can help with fits a list. Describe what you need and you'll get a straight answer on whether it's something we do and what it would cost - and if it isn't, a referral to someone who does.

Estimated fees

Estimate only - assumes the same payer list for every provider. Your exact quote is confirmed in the service agreement before any work begins.

2Practice / Group information

Legal business name *Must match your IRS records (CP 575 / Letter 147C) character for character - payers verify it against your Tax ID.

DBA / doing business as (if different)

Entity type *

Tax ID (EIN) *

Group NPI (Type 2) * (the organization's NPI - not any individual provider's)

Primary taxonomy / specialty of the group

Group Medicare PTAN (if enrolled)

Group Medicaid ID(s) (any state, if enrolled)

Primary service location

Street address *

Suite / unit

City *

State *

ZIP *

Additional service locations (one per line: street, city, state, zip)

Billing / correspondence

Billing / pay-to address (if different from service location)

Main phone *

Fax

Website

Authorized contact for this engagement

Contact name *

Title

Email *

Phone *

Our practice requires a Business Associate Agreement (BAA)
We'll send our standard mutual BAA for countersignature during onboarding.

2Your billing setup

How do you bill payers? *

Entity legal name

Entity type

EIN

Type 2 (group) NPI (if you have one)

Primary practice address (where you see patients) *

Billing / correspondence address (if different)

3Provider(s) to credential

4Which plans do you want to be in network with?

Pick what you already know. If you are not sure yet, leave it and we will work it out with you after the intake. Medicare and Medicaid are $500 each per provider; each commercial plan is $200 per provider.

Medicare
Original Medicare (PECOS enrollment) Medicaid
Your state program and its managed-care plans Commercial plans
Blue Cross, Aetna, UnitedHealthcare, Cigna and local networks Not sure yet
We will recommend plans for your area after the intake

If you pick Medicare or Medicaid too, we also join each plan's Medicare Advantage or Medicaid network for you. No need to list those separately.

Practice ZIP code

State(s) where you need enrollment

Other plans (comma-separated)

Anything else about your payer needs (plans you are already in, pending applications, prior terminations, timing)

6Documents: file rules & anything extra

File rules for every upload on this form: PDF is preferred (it's what payers accept everywhere); clear photos or scans as JPG or PNG are also fine. Max 10 MB per file. Make sure the whole document is visible (all four corners), text is readable, and nothing is cut off or expired. You don't need originals - legible copies are what payers want.

Document upload boxes appear throughout the form next to the information they belong to. Anything you can't upload today, we'll request through a secure channel after intake - please don't email documents unencrypted. CAQH or portal passwords are never uploaded here; we collect login access separately through a secure channel.

Anything missing, expired, or on its way? (tell us here)

8Authorization & payment consent

(a) Authorization to act on your behalf. I authorize Provider Enrollment Credentialing Services to prepare, submit, and manage credentialing and payer enrollment applications for the provider(s) listed in this intake; to communicate with payers, CAQH, licensing boards, and verification sources on our behalf; and to receive application status information. Specifically, each provider agrees to: (a) add Provider Enrollment Credentialing Services as an authorized user on their CAQH profile (or grant equivalent access), (b) approve Provider Enrollment Credentialing Services's surrogacy request in the CMS Identity & Access (I&A) system so we can file and manage Medicare/PECOS applications on their behalf, and (c) approve access requests in payer portals (e.g., Availity) when prompted - we'll send simple step-by-step instructions for each. This authorization remains in effect for the duration of our engagement and may be revoked in writing at any time. (b) Payment terms. I understand that Provider Enrollment Credentialing Services operates fully digitally via Stripe - ACH bank payment preferred, card accepted, no paper checks. Nothing is due to submit this intake; each service begins once its own invoice is paid. Enrollment services (Medicare, Medicaid, commercial applications) bill half at engagement and half at that application's approval; CAQH, Availity, NPI, EIN and group onboarding bill when engaged; contract rate negotiation bills only on a successfully improved contract. Ongoing maintenance bills $100 per provider per quarter via ACH autopay beginning with the quarter of that provider's first payer approval; autopay authorization is completed before the first maintenance invoice. (c) Accuracy. I certify that the information provided in this intake is true, complete, and current to the best of my knowledge, and I agree to promptly notify Provider Enrollment Credentialing Services of any changes (license status, address, malpractice coverage, adverse actions) during the engagement.

(d) Signature authorization: recommended. Credentialing regularly requires quick-turnaround signatures on routine forms (payer paperwork, e-signature requests) - often while you're with patients or traveling. Choose one:

I authorize Provider Enrollment Credentialing Services to apply my electronic signature to routine credentialing forms on my behalf when I'm unavailable. (Avoids delays when a signature is needed while you're unavailable. Never used for payer contracts or anything creating new obligations without your review.) I prefer to sign everything myself. I understand this can add delays when a signature is needed and I'm not available.

Signature (type your full legal name) *

Title / credentials

Date *

Typing your name above constitutes your electronic signature on this intake. The formal service agreement follows separately for e-signature.

✓Finish

By submitting you agree to our Terms. How we handle your information: Privacy Policy.

What a complete file looks like

1Who is this intake for?

5What services are you interested in?

Estimated fees

2Practice / Group information

Primary service location

Billing / correspondence

Authorized contact for this engagement

2Your billing setup

3Provider(s) to credential

4Which plans do you want to be in network with?

6Documents: file rules & anything extra

8Authorization & payment consent

✓Finish

Provider 1

Start with your CV

Identity

Identifiers

State licenses

DEA & controlled substances (if prescribing)

Education & training

Work history: last 5 years

Malpractice insurance

Collaboration (NPs/PAs, in states that require physician collaboration or supervision)

Disclosures