Medical credentialing has always been difficult, no doubt about that. However, 2025 brought the biggest medical credentialing change in decades. The new regulations from NCQA and CMS completely changed the medical credentialing process. Practices that were used to the old, yearly timeframe now face monthly verification requirements along with significantly shorter approval windows.
With these changes, it’s now necessary for practice owners to understand and stay current. This guide is a walkthrough of the updated medical credentialing process and what compliance really means now. Whether you’re credentialing your first provider or managing a large network, by the end of it, you’ll find actionable strategies to get credentialing done the right way.
It all started when NCQA rolled out updates to its 2025 Credentialing Product Suite, representing the most significant shift in provider verification requirements in years. July 1, 2025, marked the official start of these changes. If you changed your approach towards credentialing since then, you might already be in trouble.
Before 2025, credential checks happened every six months or during recredentialing cycles every 2-3 years. Healthcare organizations must now review every provider every 30 days for any issues, and this requirement applies to all credentialing files processed on or after July 1, 2025. Monthly reviews cover license status, OIG exclusions, state medical board actions, and SAM.gov screening. Missing a single check could mean you are practicing with expired credentials.
The timeline is also shortened, as NCQA reduced credentialing windows from 180 to 120 days for accredited organizations and from 120 to 90 days for certified organizations.
That’s a 33% reduction in medical credentialing process time, while verification requirements have increased. This means organizations will now have to complete more thorough reviews in significantly less time, forcing many to completely redesign their credentialing workflows.
With challenges introduced, so too come solutions for medical credentialing. CMS is advancing digital transformation through cloud-based credentialing systems that enable real-time data entry, automatic updates, and faster communication between providers and payers.
This is because paper-based systems create compliance risks. The volume of monthly verifications makes manual tracking nearly impossible without errors. Thus, healthcare organizations using AI-based credentialing platforms will save processing time and very few manual errors.
The Interstate Medical Licensure Compact (IMLCC) now includes 42 members with the addition of North Carolina. Note that each state still has its own requirements, renewal cycles, and documentation standards.
This means that if you have a provider seeing telehealth patients in five states, five separate license verifications and five background checks are required. CMS updated telehealth credentialing now covers audio-only services for Medicare when patients cannot or prefer not to go with video.
The industry has shifted from periodic verification to continuous monitoring. This isn’t just checking credentials at renewal time anymore. You’re essentially running an ongoing surveillance operation.
Current regulations emphasize timely entries, accurate data, and increased transparency in the credentialing process, with CMS and state regulators enforcing stricter compliance standards. The risk of non-compliance? You could lose federal program participation and see revenue stop flowing immediately.
The medical credentialing process has specific steps that must happen in sequence, with a few changes being made with the recent updates. As a physician, understanding this new workflow will help you avoid delays, reduce errors, and maintain compliance throughout the provider lifecycle.
Every successful medical credentialing process starts with complete documentation. Missing even one document creates delays that can cost providers thousands in lost revenue.
Essential documents include:
Important Note:
Over 2.5 million providers use CAQH ProView, and most major health plans accept it as their primary data source. Keeping this profile current streamlines applications across multiple payers and prevents repetitive data entry.
Credentialing verification requires confirming every credential directly with the issuing organization. You can’t just accept a provider’s documentation; you must verify it with medical schools, licensing boards, certification bodies, and previous employers.
Modern automated PSV systems operate through direct API integrations with licensing boards, medical schools, and certification bodies for real-time data verification.
| Verification Method | Timeline | Accuracy Rate | Staff Hours Required |
|---|---|---|---|
| Manual (Phone/Email) | 15-30 days | 75-85% | 8-12 hours per provider |
| Automated (API Integration) | 2-5 days | 95-98% | 1-2 hours per provider |
Automated systems connect directly to primary sources and pull verified data instantly, cutting verification time by 60% or more.
Organizations now have 120 days to complete credentialing for accreditation, or 90 days for certification.
The timeline includes:
For hospital credentialing process requirements, facilities must also grant clinical privileges. This involves peer review, department chair approval, and credentialing committee evaluation, adding 30-45 days beyond the insurance medical credentialing process.
Once verification is complete, the credentialing committee will review it. They examine credential accuracy, identify any red flags, and determine if the provider meets the criteria for network participation.
Possible outcomes:
Approval doesn’t automatically mean you can bill. Payer enrollment finalizes the provider’s participation in the network and establishes:
Know that Medicare requires separate PECOS enrollment. On the other hand, Medicaid has state-specific processes. Commercial payers each have their own systems.
Organizations must now review every provider every 30 days for any issues.
Monthly monitoring checklist:
Real-time monitoring systems flag issues immediately, such as expired licenses, new disciplinary actions, or federal exclusions, preventing compliance violations before they impact your practice.
Medical credentialing now demands monthly monitoring, faster timelines, and automated systems. Organizations that adapt to these changes maintain compliance and protect revenue. Those who don’t understand the new medical credentialing process face billing disruptions and potential federal program participation issues.
So if you’re adding providers or expanding telehealth services, let us handle the complexity of medical credentialing for you while you focus on patient care. Contact us for a free credentialing assessment.
By outsourcing your billing services to us, you can expect revenue growth of up to 20%
Please provide the following information, so our team can connect with you within 12 hours.
Or call us as 800-640-6409
