Insurance Credentialing for DMEs: The Complete Process

Before you can bill insurance for CPAP equipment and services, you need to be credentialed. This process takes 60-180 days depending on the payer. Start now.

Understanding Credentialing vs. Contracting

Credentialing: Verification that your business meets payer requirements (licenses, accreditation, compliance history).

Contracting: Negotiating reimbursement rates and signing a provider agreement.

You need both. Credentialing comes first.

Medicare Enrollment (Required)

If you're billing Medicare for CPAP, you must enroll through PECOS (Provider Enrollment, Chain, and Ownership System).

Requirements Checklist

Business requirements:

• State DME license
• National Provider Identifier (NPI)
• DMEPOS accreditation (from CMS-approved organization)
• Surety bond ($50,000 minimum)
• Business liability insurance
• No exclusions from federal healthcare programs

Location requirements:

• Physical location (no P.O. boxes)
• Accessible to the public
• Proper signage
• Maintained inventory or display of products

Enrollment Steps

1. Apply for NPI (if not already obtained)

- Use NPPES (National Plan and Provider Enumeration System)

- Takes 10-20 days

1. Obtain DMEPOS accreditation

- Choose accreditor (ABC, BOC, HQAA, etc.)

- Process takes 60-90 days minimum

- Cost: $3,000-8,000 depending on accreditor

1. Get surety bond

- Must be from Treasury-approved surety

- Costs $500-2,000 annually

- Names CMS as obligee

1. Submit PECOS application

- Complete CMS-855S form online

- Include all required documentation

- Pay $631 application fee

1. Site visit (may be required)

- Medicare contractor visits your location

- Verifies information in application

- Can happen without notice

Timeline: 60-120 days after complete application submitted.

Medicaid Enrollment

Each state runs its own Medicaid program. You'll need to enroll separately in each state where you serve Medicaid patients.

General Requirements

• Active Medicare enrollment (some states require this first)
• State-specific DME license
• Medicaid-specific application and fees
• May require separate accreditation verification

Tips

• Start with states where you have the most Medicaid patients
• Some states use fiscal intermediaries for DME, requiring additional enrollment
• Reimbursement rates vary significantly by state

Timeline: 30-90 days per state.

Commercial Insurance Credentialing

Private payers have their own credentialing processes. Major ones to consider:

Priority Payers (by market share)

1. UnitedHealthcare
2. Anthem/Blue Cross Blue Shield (varies by state)
3. Aetna
4. Cigna
5. Humana

Common Requirements

• CAQH ProView profile (universal credentialing database)
• Proof of Medicare enrollment
• Professional liability insurance ($1M minimum typical)
• Business licenses
• W-9 and banking information for EFT

Process

1. Complete CAQH ProView profile

- Free for providers

- Many payers pull data from here

- Keep it updated quarterly

1. Submit applications to individual payers

- Some accept CAQH data directly

- Others require their own forms

- Each has unique requirements

1. Follow up relentlessly

- Applications stall without attention

- Call credentialing departments monthly

- Document every interaction

Timeline: 90-180 days per payer.

Credentialing Pitfalls

1. Incomplete Applications

Missing documents cause automatic delays. Create a checklist, double-check everything before submission.

2. Expired Accreditation

DMEPOS accreditation must remain current. Mark renewal dates, start process 6 months early.

3. Address Mismatches

Every document must show the same business address. One discrepancy can restart the process.

4. Ownership Changes

Any change in ownership requires notification to all payers. Some require re-credentialing entirely.

5. Exclusions

If anyone in your organization has been excluded from federal healthcare programs, your application will be denied. Run OIG exclusion checks regularly.

Maintaining Credentials

Credentialing isn't one-time. Ongoing requirements include:

Annual:

• Update CAQH ProView
• Renew surety bond
• Update liability insurance
• Pay Medicare revalidation fees (if applicable)

Every 3-5 years:

• Medicare revalidation
• Accreditation renewal
• State license renewal (varies)

As needed:

• Report any changes within 30-90 days (depending on payer)
• Address changes, new locations, ownership changes, etc.

Credential Tracking System

Create a tracking spreadsheet:

Update weekly. Assign responsibility to specific staff member.

While you're getting credentialed, set up your compliance infrastructure. Drift integrates with all major payers for streamlined billing. [Learn more →](/support)