Direct Answer
New healthcare providers must complete several steps before billing can begin: obtaining NPI numbers, completing provider credentialing with each payer, completing payer enrollment to get billing privileges, selecting and implementing a PMS/EHR, and establishing billing workflows. This process takes 90–180 days for most providers — start as early as possible before your intended opening date.
Table of Contents
NPI and Tax ID Requirements
Every healthcare provider who submits HIPAA-standard transactions must have a National Provider Identifier (NPI). Individual providers receive a Type 1 NPI. Organizations (group practices, hospitals, clinics) receive a Type 2 NPI. New providers should obtain their NPI through NPPES (National Plan and Provider Enumeration System) as early as possible in the startup process — NPIs can be obtained in days, and many payer applications require them.
Along with the NPI, providers need a federal Tax Identification Number (TIN) — either your Social Security Number (for sole proprietors) or an Employer Identification Number (EIN) from the IRS. Group practices will use the group's EIN. The NPI-TIN combination is what uniquely identifies a billing entity to payers — both must be accurate and consistent across all payer applications and claims.
Provider Credentialing
Credentialing is the process by which payers verify a provider's qualifications — licenses, education, training, board certifications, malpractice history, and work history — before granting billing privileges. This is distinct from enrollment (the administrative process of setting up a billing relationship). Most payers require credentialing to precede or accompany enrollment.
The credentialing application requires: current state medical license; DEA registration (if applicable); board certification certificates; malpractice insurance certificate; CV or practice history; ECFMG certificate (for international medical graduates); hospital privileges (if applicable); and work history for the past 10 years. The CAQH ProView database — a shared credentialing repository used by most payers — allows providers to complete one comprehensive profile that payers can access rather than completing separate applications for each payer. Register with CAQH early.
Payer Enrollment
Payer enrollment establishes your billing relationship with each payer — setting up your practice in their payment system so claims can be processed and payments directed to you. Each major payer requires a separate enrollment application. Medicare enrollment is completed through the Provider Enrollment, Chain, and Ownership System (PECOS). Medicaid enrollment varies by state. Commercial payer enrollment is completed through each payer's contracting department or the CAQH enrollment process where supported.
Plan your payer enrollment timeline carefully. Medicare enrollment can take 60–90 days. Major commercial payer enrollment typically takes 60–120 days. Medicaid enrollment timelines vary widely by state. Providers who haven't completed enrollment cannot bill those payers — and claims submitted before enrollment is complete will be denied. Start enrollment applications as soon as you have your NPI, even if your practice opening date is months away.
Note the retroactive billing limitation: Medicare and most payers don't allow you to bill for services delivered before your enrollment effective date — meaning you generally can't bill for services rendered during the enrollment waiting period once enrollment is approved. This makes early enrollment initiation a financial imperative.
Setting Up Your Billing Workflow
Once credentials and enrollment are in place, establish your billing workflow: select and implement a practice management system (PMS) and EHR; connect to a clearinghouse for electronic claim submission; set up ERA (electronic remittance advice) enrollment with each payer for automated payment posting; establish fee schedules in the PMS aligned with your payer contracts; and implement a patient registration and eligibility verification workflow. Staff need training on each component before the first patient is seen.
Common First-Year Billing Mistakes
- Starting enrollment too late: Enrollment takes months; providers who start after opening are often unable to bill major payers for their first several months
- Incorrect NPI on claims: Using individual NPI when the group NPI is required, or vice versa — leads to automatic rejections
- Missing CLIA certificate for labs: Practices performing lab tests in-office need a CLIA certificate before billing for them
- Not verifying eligibility: Assuming insurance information on the new patient form is current and accurate — many patients have coverage changes that haven't been communicated
- Waiting to appeal denials: New practices sometimes let early denials age while focused on clinical operations — timely filing deadlines don't pause for startup chaos
FAQ
Can new providers see patients and bill before completing all payer enrollments?
Yes — you can see patients before all enrollments are complete, but you can only bill the payers for which you are enrolled. Patients with unenrolled payer coverage would need to be treated as self-pay, or you would need to document their consent to be treated before your enrollment is effective and bill them when enrollment is granted, if the payer allows retroactive billing. Most providers prioritize enrolling with Medicare and their highest-volume commercial payers first to ensure they can bill for the majority of their patient population from day one.
Should new providers handle billing in-house or outsource?
For most new solo practitioners and small group practices, outsourcing billing to an experienced RCM company is the more financially sound choice. Hiring, training, and managing in-house billing staff requires significant time and management attention that new practices rarely have. A quality RCM partner brings immediate expertise, established payer relationships, and denial management capability that would take an in-house team years to develop. As the practice grows and billing volume increases, in-house billing may become more cost-effective — typically at 5+ providers or high-volume single-specialty groups.
Start Your Practice Right with Expert Billing from Day One
Valiant Lifecare helps new healthcare providers navigate credentialing, payer enrollment, and billing setup — so you start generating revenue as quickly as possible without the billing learning curve slowing you down.
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