Credentialing in New York: how long it takes, plan by plan

New York law gives state-regulated insurers and HMOs 60 days from a completed application to tell a provider whether they’re credentialed. If a third party is slow to send documents, the plan can take 21 more days after it receives them. Some providers who join an already-participating group become “provisionally credentialed” if the plan hasn’t decided by day 60. NY Medicaid and Medicare don’t publish processing times, and self-funded plans and Medicare Advantage plans aren’t covered by the New York rule. The 60-day clock also starts only when the application is complete, so a missing document can hold things up before the clock even starts.

This guide covers what the law requires, what each enrollment involves, and a checklist for adding a provider. Every timeline here is a published target or a legal deadline. None is a promise about a particular plan or application.

Credentialing, enrollment and contracting are different steps

People use “credentialing” for three separate things:

• Enrollment with a government program (NY Medicaid, Medicare) so the provider can bill it at all.
• Credentialing by a health plan, which checks the provider’s license, training, board status, malpractice history and sanctions.
• Contracting, the participation agreement that sets the fee schedule and which entity (individual or group) is in network.

A provider can be credentialed and still not be billable if the contract or the group linkage isn’t loaded. Track all three for each plan.

New York’s 60-day rule

Insurance Law §4803 (for insurers offering managed care products) and Public Health Law §4406-d (for HMOs) say the same thing. Once the plan receives a completed application to join its network, it has 60 days to tell the provider either:

• whether they are credentialed, or
• that it needs more time because a third party hasn’t sent necessary documents. In that case the plan must make every effort to get them and decide within 21 days of receiving them.

Both laws also require the plan to disclose its written application procedures and minimum qualification requirements on request (NY Ins. Law §4803; NY PHL §4406-d, both as of November 2026).

Plans repeat this in their manuals. Healthfirst, for example, says its credentialing department reviews initial applications within 60 days of a completed application and notifies the provider within 21 days if more information is needed (Healthfirst NY Provider Manual, section 3.6, updated November 2026).

What the rule doesn’t cover:

• Self-funded employer and union plans. These follow federal law, not the New York Insurance Law.
• Medicare and Medicare Advantage. Medicare enrollment is federal (see below). Medicare Advantage plans run their own credentialing.
• Incomplete applications. The 60 days start from a completed application. An expired CAQH attestation or a missing malpractice certificate can leave an application “incomplete” without anyone telling you.

Provisional credentialing for new and relocating providers

The same two laws let some providers start seeing a plan’s members as in-network before the plan decides. A provider is deemed provisionally credentialed if all of these are true:

• They are newly licensed, or recently moved to New York from another state and haven’t practiced here before.
• They are joining a group practice in which every health care professional already participates with that plan.
• The plan hasn’t approved or declined their completed application within 60 days.
• The group has told the plan in writing that if the application is ultimately denied, the group or provider will refund in-network payments above the out-of-network benefit and won’t bill the patient beyond normal cost-sharing.

Network participation then starts on the day after the 60th day and lasts until the plan’s final decision. A provisionally credentialed physician can’t be designated as a member’s primary care physician until fully credentialed. The statute also says the plan can’t deny, after appeal, a claim for services by a provisionally credentialed professional solely because it wasn’t filed on time.

There is a separate provision for physicians employed by hospitals and some licensed facilities, tied to hospital privileges. Aetna’s New York supplement and Healthfirst’s manual both restate these rules (Aetna State Supplement).

In practice, provisional credentialing helps a group whose providers all participate with the plan. If even one provider in the group doesn’t participate with that plan, the condition isn’t met.

NY Medicaid enrollment (eMedNY)

New York Medicaid enrollment now runs through the Provider Services Portal (PSP). The steps, from the eMedNY enrollment guide and the PSP page:

1. Get an NPI from NPPES if the provider doesn’t have one.
2. Get portal access: a Health Commerce System (HCS) account or an NY.gov business account. Licensed New York professionals can apply for HCS using their license.
3. Start the application in the PSP. An incomplete application can be saved and finished within 45 days. After 45 days it’s deleted and you start again. Answer any requests for information quickly, or the application can be withdrawn.
4. NYS Department of Health reviews it and sends a written determination. An approval includes the Medicaid provider ID and the effective date of enrollment.
5. Set up billing: a new provider completes the Certification Statement for Provider Billing Medicaid (form 490602) for an ETIN, or form 490501 to join an existing ETIN, such as a group’s. Wait for confirmation before sending claims.

Neither eMedNY nor the Department of Health publishes a processing time for new applications. Plan for that uncertainty instead of guessing at a number.

Two other Medicaid rules affect timing:

• Managed care requires fee-for-service enrollment. Under the 21st Century Cures Act, every Medicaid managed care network provider must be enrolled with the state Medicaid program, and plans remove providers who aren’t (eMedNY managed care network enrollment). Enroll with eMedNY before or alongside Healthfirst, Fidelis and the other Medicaid plans.
• Revalidation. Federal rules require revalidation at least every five years. New York uses three-, four- and five-year cycles by risk level, sets the deadline in the notice it sends, and terminates enrollment if revalidation isn’t done by then. eMedNY says the state is revalidating all providers by June 2028, and all revalidations now go through the PSP (NYS Medicaid provider revalidation; eMedNY revalidation). Watch for email from ProviderEnrollment@acentra.com, which eMedNY names as the sender.

New York has also paused new enrollments for some provider classes, such as labs, DME suppliers, ABA providers, home care agencies and pharmacies. Check the revalidation page if your practice owns one of those.

CAQH: keep the profile attested

Many plans pull credentialing data from CAQH (its provider tool is now called the Provider Data Portal, formerly ProView). CAQH says providers must re-attest at least every 120 days, and a profile that isn’t attested in time changes to “Expired” (CAQH FAQs). Healthfirst, for one, requires all applicants to complete the CAQH application and asks that it stay attested every 120 days.

An expired attestation is one of the easiest ways to stall an application. Put each provider’s next attestation date on a calendar.

Medicare enrollment, briefly

Medicare enrollment is through PECOS (or the CMS-855 paper forms). Two timing rules matter:

• The effective date for physicians and non-physician practitioners is the later of the date the application that was approved was filed, or the date the provider first started services at the new location (42 CFR 424.520(d)).
• Retroactive billing is allowed for up to 30 days before the effective date if circumstances prevented enrolling in advance, or 90 days after a presidentially declared disaster (42 CFR 424.521).

In other words, Medicare doesn’t pay for months of services provided before you applied. File before the start date. Medicare enrollment also has to be revalidated every five years (42 CFR 424.515).

What actually slows applications down

An application that isn’t complete doesn’t start the 60-day clock. Things that commonly leave one incomplete or stuck:

• A CAQH profile that is unattested, missing documents, or doesn’t grant the plan access.
• A malpractice certificate, DEA registration or board certificate that has expired or will expire during review.
• Gaps in work history with no explanation.
• Practice location, tax ID or NPI data that doesn’t match between CAQH, NPPES, the application and the group roster.
• No one following up after the application is sent.

Checklist: adding a provider to a New York practice

Start as early as you can, ideally when the offer is signed.

1. Confirm the provider’s NPI (individual) and the group’s NPI and tax ID. Update NPPES if the practice address is new.
2. Collect: New York license, DEA and any state controlled-substance registration, board certification, malpractice face sheet, CV with month-and-year work history, diploma and training certificates, hospital privileges letter if applicable.
3. Create or update the CAQH profile, upload documents, grant access to each plan, and attest.
4. Start the NY Medicaid PSP application and finish it within 45 days. Then file the ETIN form.
5. File Medicare enrollment in PECOS before the provider’s first day with Medicare patients.
6. Send each commercial and managed care plan its application, and record the date each one was complete. The 60-day clock starts there for New York-regulated plans.
7. If the provider qualifies for provisional credentialing, send the plan the written notice the law requires.
8. After approval, confirm the provider is linked to the group contract, the effective date, and the plan’s provider ID before you bill.
9. Diary every attestation and revalidation date: CAQH every 120 days, NY Medicaid when notified, Medicare every five years, and each plan’s recredentialing cycle (Healthfirst and Fidelis say every three years).

Example only: a provider starts on March 1, 2027, and the applications are complete on January 2, 2027. Day 60 at New York-regulated plans is March 3, two days after the start date. If any document was missing on January 2, the clock hadn’t started yet.

Marlow’s credentialing service enrolls new providers, keeps CAQH current and tracks revalidations, priced per provider (see services). The checklist above works either way.

Sources

• NY Insurance Law §4803 (credentialing applications, provisional credentialing)
• NY Public Health Law §4406-d (HMO credentialing applications)
• Healthfirst New York Provider Manual, section 3.6
• Aetna Provider Manual State Supplement (New York provisional credentialing)
• Fidelis Care Provider Manual
• eMedNY: Provider enrollment guide
• eMedNY: Provider Services Portal
• eMedNY: Medicaid managed care network provider enrollment
• eMedNY: Revalidation information
• NYS Department of Health: Medicaid provider revalidation
• CAQH: Provider Data Portal FAQs
• CMS NPPES (NPI registry)
• CMS PECOS
• 42 CFR 424.520 (Medicare effective date of billing privileges)
• 42 CFR 424.521 (Medicare retroactive billing)
• 42 CFR 424.515 (Medicare revalidation)

General information, not advice on a specific claim, contract or legal question. Rules and rates change; check the linked sources for the current version.