Caqh credentialing

This is a question often asked by our clients and we figured it would be useful just to publish a quick  post to clear up any confusion.  CAQH is used by commercial insurance companies like BCBS, Aetna, UHC, Cigna, and others as a credentialing repository/database.  CAQH is used by some states to aid in Medicaid enrollment, but that is certainly an exception rather than a rule. Medicare is administered by numerous different carriers such as Novitas, First Coast Service Options, Palmetto GBA, WPS, Highmark, etc., and each of these carriers has to bid every 3-5 years in order to keep their government contract.  Because of the competitive bidding process, it is imperative that they keep their costs very low which is why none of them as of 2022 utilize CAQH for credentialing. Now CMS has their own CAQH of sorts in the form of PECOS.

CAQH is simply a repository of information which means that you or someone in your office could use CAQH to aid in the completion of Medicare applications but you would still need to actually complete the information.  CAQH is a great time saver if used as a storage place for important documents and information, but does not do any of the actual credentialing or contracting for providers. You use CAQH as a tool but still need to complete the credentialing process with each payer that you are interested in participating with.  Credentialing involves primary source verification which must be completed by each organization including Medicare each time you request to participate.

To be clear, Medicare does not use CAQH but you can use the information stored in CAQH (If updated with your current information) to aid in the completion of Medicare enrollment applications.  

Additional information:

More information CAQH

PECOS Medicare Application Status

PECOS Login & Information

Updated: 9.20.2022

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