Credentialing · 10 min read
NPI, CAQH, Credentialing—When Can Your OT Practice Bill?
An NPI identifies you, CAQH organizes profile data, and each payer makes its own approval decision. This guide separates the steps so you know what is finished, what is still pending, and when you can actually submit a claim.
The short version
What to know before you start.
- Keep individual and organization identifiers matched to the intended billing structure.
- Treat CAQH as a shared data profile, not payer approval.
- Track application, credentialing, contract, effective date, and billing test separately.
Start with the payment route
Decide which payer or program you are evaluating and whether you intend to bill as an individual, group, organization, supplier, contractor, or facility. The required identifiers and enrollment path depend on that structure. Create only the records your own arrangement and payer process require.
What an NPI does
An NPI is the standard healthcare identifier used in many enrollment and billing processes. Licensure, credentialing approval, network contracts, and permission to bill each require separate steps. CMS directs providers to obtain an NPI through NPPES before completing Medicare enrollment. Confirm whether you need an individual Type 1 NPI, an organization Type 2 NPI, or both for your structure and payer contracts.
Keep legal name, taxonomy, address, contact, authorized official, and other records consistent across NPPES, state licenses, IRS records, banking, CAQH, payer applications, and claims systems. Small mismatches can create delays.
Build the credentialing file once
Prepare current licenses, education and training history, work history, professional liability coverage, ownership and entity records, tax form, NPI confirmation, practice locations, disclosures, and payer-specific information. Store sensitive documents in an access-controlled founder-owned system—not in general notes or manager messages.
Maintain a master data sheet with exact names, dates, addresses, and renewal dates. Update the source record first, then downstream profiles.
What CAQH contributes to credentialing
CAQH describes its Provider Data Portal as free to providers. You enter professional and practice information, authorize selected participating organizations to access it, attest to accuracy, and keep it current. CAQH says providers should review and update information quarterly, and sooner when something changes.
A complete, current CAQH profile supplies data that participating organizations may use in their own credentialing process. Each payer still completes and communicates its own decision.
Keep the six payer steps separate
For each payer, record panel availability, application date, reference number, missing items, credentialing decision, contract receipt, negotiated or offered terms, signed date, effective date, directory status, portal access, electronic claim enrollment, electronic remittance, and first clean-claim test.
Wait for the payer to confirm the effective relationship before telling clients you are in network. Credentialing approval and a fully executed network contract may occur at different times.
Treat Medicare as its own pathway
CMS uses PECOS and Medicare Administrative Contractors for enrollment. Follow the current provider/supplier application instructions for your exact practice arrangement. CMS also currently states that occupational therapists are not eligible to opt out of Medicare. That can affect private-contract assumptions for Medicare beneficiaries, so obtain qualified billing or legal guidance before choosing a route.
Maintain the records after approval
Maintain credentialing through a recurring calendar. Track license and insurance renewals, CAQH attestations, revalidation, address and ownership changes, roster updates, directory checks, expiring portal users, and payer notices. Assign one source of truth and audit it at least quarterly.
Sources
Check the rules for yourself.
- CMS: Provider enrollment
- CMS: Enrollment applications
- CMS: Manage your enrollment
- CAQH: Provider Data Portal fact sheet
These sources support the claims in this guide, but requirements can change. Confirm the current rules with your state, payer, insurer, and advisers before you act.
How we worked on this guide
Research first. Advice second.
OT Bestie checks material claims against the sources above and revises time-sensitive details as the guidance changes. Use this article to plan your questions and next steps, then bring decisions that depend on your circumstances to the right legal, tax, billing, insurance, or clinical professional.