The CAQH profile mistakes that stall an application. Each one can be closed before the file goes in.

CAQH ProView is the shared profile where a provider's license, training, work history, malpractice cover and practice locations live. Most commercial payers read it instead of sending a questionnaire of their own. Each payer still takes its own application for each provider.^A

So one weak profile slows every commercial application that leans on it. A payer that finds a problem seldom says no. It holds the file and asks a question, and nothing moves until someone answers. The mistakes below are the ones that start those questions.

The attestation has lapsed.

CAQH asks every provider to re-attest the profile on a set cycle, confirming that what it holds is still true.^B A profile past its attestation date reads as out of date, and a payer reviewing the file asks for it to be brought current before the review goes on.

It lapses in two common ways. The provider built the profile at a former employer, where someone else kept the dates, and nobody picked them up at the new practice. Or the profile was current on the day of filing and fell due while the application waited in a commercial payer's queue. We re-attest before we file and write the next due date into the practice's enrollment file.

The profile and NPPES tell different stories.

NPPES is the national register of NPIs that CMS keeps and publishes.^C It holds each provider's name, practice address and specialty taxonomy. Payers compare it with the CAQH profile and with the application in front of them. When the three disagree, the file waits while someone explains which one is right.

The usual differences are small. A suite number that changed, a mailing address from residency, a taxonomy for a specialty the provider no longer practices, a name that changed after marriage on one record and not the other. Each takes a few minutes to correct at the source. We read both records side by side for every provider and fix NPPES first, since the others copy from it.

The profile is not released to the plan.

A complete profile does nothing for a payer that cannot open it. ProView lets the provider choose which health plans may view the profile, either every participating plan or a named list. A provider who picked a short list at a former job, then joins a practice that files with a plan outside it, has a profile that plan cannot read. Because each payer takes its own application for each provider, each one has to be able to see the profile on its own.^A We check the release against the list of plans on the practice's filing order before a single application goes out.

A document expires while the file is open.

The state license, the DEA registration, board certification and the malpractice certificate of insurance each carry an expiry date, and the profile holds a copy of each. An expired copy starts a request. So does a gap in the work history with no explanation beside it, since credentialing staff read the history line by line.

Timing makes this worse than it looks. A commercial plan takes months to finish its review, Medicare tends to move sooner, and each state sets its own Medicaid pace.^A A certificate that was valid on the day of filing can lapse before a commercial plan finishes its review. We list every expiry date at the start, renew anything that falls due while the file is likely to be open, and we write a short explanation for any gap in the history before a payer asks for one.

The new practice location is missing.

This is the mistake that hides longest. A provider joins a new practice, or a practice opens a second office, and the profile still lists only the old address. The provider believes they are enrolled, billing believes the claims are clean, and the gap shows only when a claim from the new location comes back denied.^D

Groups see the result. In an MGMA Stat poll, 54% of medical groups said credentialing-related denials were rising.^E It was a single-question poll of members, and not a recent one, but it points at the same place. We add every location, with its hours and the group's tax ID, before any payer is asked to link the provider to it.

What we do before anything is filed.

We build or repair each provider's profile, attest it, match it to NPPES, bring every document current and release it to each plan on the filing order. Setting up one provider's CAQH profile is $150. The applications then go to each payer in order, and we follow every one until the payer sets an effective date.

Medicare is the exception to all of this. It enrolls through PECOS, its own system, and it does not read CAQH. A clean profile helps with the commercial plans and leaves the Medicare file to be built on its own terms.