The 60-day credentialing clock.

CMS allows Medicare Advantage plans to provisionally credential providers for up to 60 days — which means a provider can see members and have claims paid while the full credentialing process is still in motion, as long as the application was complete and there were no adverse findings on the preliminary checks. This provision exists specifically to help plans manage the gap between contracting and full credentialing at go-live.

Most plans know this rule exists. Far fewer actually plan their go-live timeline around it. The result is predictable: with six weeks to go before launch, the credentialing team realizes that 40% of contracted providers are not going to complete full credentialing before day one, the plan scrambles to invoke provisional credentialing, and someone has to explain to the compliance team why this wasn't in the original plan.

What provisional credentialing actually requires

Provisional credentialing under CMS guidelines is not a blank check. To use it, you need to have completed a set of preliminary verifications: license verification, DEA registration check, NPDB (National Practitioner Data Bank) query, and a Medicare exclusions check (OIG and SAM). The provider's application needs to be substantively complete — not a skeleton application, but the real thing with all required information present.

If any of those preliminary checks surface an adverse finding, provisional credentialing does not apply. You have to complete the full process, which means a committee review, which means your next committee date. If your committee meets monthly and the adverse finding surfaced two weeks after the last meeting, you are waiting six weeks. That is a problem if your go-live is in three.

The 60-day clock starts the moment you begin providing services under provisional status. If a provider is provisionally credentialed at day one of your plan year, full credentialing must be complete by day 60. If it is not — if the full committee review hasn't happened or if primary source verification is still outstanding — you are not in compliance, and you may not be able to pay claims for services rendered after day 60.

Building your credentialing calendar before the build starts

The credentialing calendar is one of the first things we build in a diagnostic. Here is how we do it:

• Map every committee meeting date between now and three months after go-live. Include the credentialing committee, any delegated credentialing arrangements, and any peer review committees that have to sign off before files go to the credential committee.
• Calculate the file completion deadline for each meeting date. Most committees require files to be complete and reviewed by staff a certain number of days before the meeting — often 10 to 14 days. Work backward from the meeting date to get the file completion deadline.
• Map your contracting velocity against those deadlines. If you expect to execute 30 contracts between months two and four of the build, how many of those files will be complete in time for the pre-go-live committee meeting?
• Calculate your provisional credentialing exposure. The providers who won't make the pre-go-live committee meeting are your provisional credentialing population. Size that group early so compliance isn't surprised.

The CAQH factor

Most credentialing workflows depend on CAQH ProView for primary source data. When a provider's CAQH profile is complete and current, credentialing moves faster. When it's stale or incomplete, everything stalls while you chase the provider to update their information.

CAQH profiles require re-attestation every 120 days. A provider who credentialed with your plan two years ago and hasn't touched their CAQH profile since then may have a profile that's been marked inactive. Before you start the credentialing clock on any provider, verify their CAQH status. Discovering a stale CAQH profile when a file is supposed to be going to committee adds two to three weeks you don't have.

Credentialing lead times are fixed by regulation and committee schedules. No amount of urgency from your go-live team changes them. Plan for what is actually possible, not what you wish were possible.

Staffing the credentialing function

Network builds almost always understaff credentialing relative to the volume they generate. Contracting outreach runs for four to six months; the credentialing function then has to process all of those contracts in the final eight to ten weeks of the build. That is a workload problem that needs to be sized and staffed before the build starts, not after the contracting pipeline starts clearing.

If your credentialing team cannot process the projected volume in the available time, you have three options: add staff, add capacity through a credentialing CRO, or plan for more providers to come in under provisional credentialing. All three are manageable. None of them is manageable if you discover the problem in week ten.