Medicare and Medicaid are two major government health insurance programs, but their credentialing processes differ significantly for providers. Medicare is a federal program for seniors and certain disabled individuals, managed uniformly
by the Centers for Medicare & Medicaid Services (CMS). Medicaid is jointly funded by the federal and state governments, so each state runs its own program with varying rules.
Credentialing rules differ because Medicare follows national standards through PECOS, while Medicaid enrollment is state-specific with different portals, documents, and timelines. Understanding these differences helps providers enroll correctly and avoid billing delays.
In this article, we’ll break down what Medicare and Medicaid credentialing involve, compare requirements and timelines, highlight common challenges, share best practices, and explain how to streamline the process.
Key Takeaways
- Federal vs. State Control: Medicare is a uniform federal program managed through the national PECOS system, while Medicaid is state-specific, requiring separate applications and portals for every state in which you practice.
- Approval Is Not Automatic: Being credentialed with Medicare does not grant you Medicaid status; you must proactively enroll in each state’s program and often in additional managed care plans.
- Variable Timelines: Expect a 60–90 day wait for Medicare, but prepare for 3–6 months for Medicaid in high-volume states like New York or California.
- Accuracy is Critical: Nearly 40% of delays are caused by simple errors like mismatched NPIs, expired licenses, or incomplete forms, which can push your start date back by several months.
- Continuous Maintenance: Compliance doesn’t end at enrollment; you must revalidate your information every 3–5 years and report practice changes within 30 days to avoid payment deactivation.
What Is Medicare Credentialing?
Medicare credentialing is the process that providers must complete to enroll with CMS, verifying qualifications to bill for Medicare patients. It’s required for any practice seeing Medicare beneficiaries, as unreimbursed claims are denied.
Use the Provider Enrollment, Chain, and Ownership System (PECOS) online for most enrollments, or submit CMS-855 forms (like 855I for individuals or 855B for groups). PECOS streamlines updates and revalidations every 3-5 years.
Enrollment proves you’re licensed, malpractice-free, and meet federal screening levels—essential for hospitals, clinics, and solo practices to get paid.
What Is Medicaid Credentialing?
Medicaid credentialing is the enrollment process for providers to bill state-run Medicaid programs for low-income patients. Unlike Medicare’s federal system, each state has its own portal, rules, and timelines, making it more variable.
States use systems like California’s Medi-Cal Provider Enrollment, Texas’s TMHP, or New York’s eMedNY—check your state’s Medicaid agency website to start. Providers must enroll separately in each state where they serve patients, even if Medicare-approved.
This step verifies eligibility to receive Medicaid reimbursements, with state-specific checks on licenses, background, and managed care plans.
Medicare vs. Medicaid Credentialing Requirements
Both programs require proof of licensure, NPI, malpractice insurance, and background checks, but differences lie in forms and depth.
Medicare uses standardized CMS-855/PECOS with three screening levels (basic, moderate, and high-risk based on service type).
Medicaid adds state-specific items like managed care attestations or W-9 forms, often with stricter site visits for high-risk providers.
| Aspect | Medicare | Medicaid |
| Primary Form | CMS-855 via PECOS | State-specific portals/applications |
| Documents | License, DEA, CV, malpractice | Same + state tax ID, Medicaid-specific attestations |
| Screening | Federal levels (low-moderate-high) | Varies; often more checks for fraud |
| Frequency | Revalidate every 3 years | State-dependent (1-5 years) |
These overlaps mean Medicare approval often speeds Medicaid, but always confirm state extras.
Medicare vs. Medicaid Credentialing Timeline
Medicare enrollment through PECOS typically takes 60-90 days for new providers, faster (21-45 days) for reassignments or changes. High-risk specialties like ambulance services can stretch to 120+ days due to extra reviews.
Medicaid timelines vary widely by state—30-90 days in efficient ones like Florida, but 120-180 days in states like New York or California amid backlogs. Managed care plans add 30-60 days.
Common Delay Factors:
- Incomplete apps (both programs: 40% of issues)
- Site visits or OIG checks (more in Medicaid)
- Peak seasons or staff shortages
- Medicare appeals can add 60 days
Start both 4-6 months ahead to avoid revenue gaps.
Common Medicare and Medicaid Credentialing Challenges
Application errors top the list, often from simple oversights like mismatched National Provider Identifiers (NPIs), incorrect Tax IDs, or incomplete CMS-855 sections in Medicare PECOS.
These mistakes trigger automatic rejections or requests for correction, pushing timelines back 30-60 days—Medicaid state portals amplify this with rigid validation rules. Always print or save a submission summary to cross-check against errors.
Missing or expired documents plague 35-40% of enrollments. For Medicare, this includes state licenses, DEA certificates over 30 days expired, board certifications, or hospital privileges lists. Medicaid demands extras like CVs formatted precisely or state-specific affidavits. Renew everything 3-6 months ahead, scan high-res copies (under 5MB), and keep a master folder organized by payer.
Revalidation and ongoing compliance create ongoing headaches. Medicare mandates PECOS updates every 36 months (or sooner if changes occur), with non-compliance risking deactivation and retroactive claim denials up to 90 days. Medicaid reval cycles differ—annual in Texas, triennial in California—and missing them halts payments; you can track them via state newsletters or apps like CredentialMyDoc.
Other frequent issues include:
- Background/Screening Delays: OIG excludes, SAM.gov issues, or felony disclosures extend high-risk reviews (e.g., DME suppliers wait 90+ days).
- Portal Glitches: Medicaid sites crash during peaks; PECOS times out on large uploads—use wired internet and submit off-hours.
- Managed Care Layers: Many Medicaid patients need separate enrollments with plans like UnitedHealthcare Community Plan, doubling work.
Track everything in a spreadsheet with columns for status, due dates, and contacts to catch issues fast.
Best Practices for Medicare and Medicaid Enrollment
Staying organized is key—create a central dashboard or spreadsheet tracking PECOS status, state Medicaid apps, document expirations, and follow-up dates for both programs. Use tools like credentialing software or folders labeled by payer to avoid scrambling during submissions.
Respond to requests quickly: CMS or state agencies send emails/portals notes for fixes—reply within 48 hours with precise info to prevent queue drops. Check PECOS weekly for Medicare and log into state portals (e.g., Provider360 in many states) daily during active apps.
Keep enrollment information updated proactively. Report address, ownership, or license changes within 30 days to avoid deactivation; set Google Calendar alerts for revalidations and use NPPES to sync NPIs across systems.
Additional Steps:
- Pre-fill CMS-855I/B annually for quick edits
- Join provider associations for state-specific tips
- Batch similar apps (e.g., Medicare first, then Medicaid)
These habits cut delays by 50% and ensure smooth reimbursements.
How Get Credentialing Done Helps With Medicare and Medicaid Credentialing
Get Credentialing Done takes the hassle out of Medicare and Medicaid enrollments by handling PECOS submissions and all 50+ state Medicaid portals for you. The team prepares and uploads documents like CMS-855 forms, licenses, and attestations, ensuring everything meets federal and state specs to avoid rejections.
They manage follow-ups, chasing CMS or state agencies for status updates, and responding to requests within 24 hours to speed approvals. Ongoing support includes revalidation reminders, change reporting, and renewals, keeping your credentials active without downtime.
Providers save 100+ hours per enrollment and cut timelines by 40%, focusing on patients instead of paperwork.
Start with a free audit of your current status today.
FAQ
Medicare is a federal program, so the rules and enrollment system (PECOS) are the same nationwide. Medicaid is administered by individual states, meaning each state has its own application process, portal, and credentialing requirements.
No. Medicare approval does not automatically enroll you in Medicaid. You must apply separately with the Medicaid agency in each state where you provide services. However, Medicare approval can sometimes help speed up parts of the Medicaid review process.
Medicare credentialing typically takes about 2 to 3 months. Medicaid timelines vary by state—some process applications within 30 to 90 days, while others, such as New York or California, may take six months or longer due to high application volume.
Delays are commonly caused by errors such as incorrect NPI or Tax ID numbers, expired licenses or DEA certificates, or incomplete application sections. Many delays occur simply because the required information is missing or inconsistent.
Medicare generally requires revalidation every three years. Medicaid requirements depend on the state, ranging from annual updates to every five years. Any major changes, such as a new office address or ownership update, must usually be reported within 30 days.
Yes. In many states, enrolling with the state Medicaid program is only the first step. If your patients are covered under Medicaid Managed Care plans, such as UnitedHealthcare Community Plan, you may need to complete separate credentialing with those insurance companies.