Medicare credentialing is the single most searched "how to" for OTPs starting a private practice, and for good reason. It is confusing, it is slow, and one mistake on your application can set you back months. But it is also completely manageable when you know what to expect and follow the process step by step.
This guide walks you through the full credentialing process from start to finish.
Before You Start: What You Need in Place
Do not submit your Medicare application until you have these items ready: your individual NPI (Type 1), your organizational NPI (Type 2) if billing under a practice entity, your LLC or business entity formation documents, your state OT license, your EIN from the IRS, and professional liability insurance.
Having these documents organized before you begin will prevent the incomplete application delays that trip up most first-time applicants.
Step 1: Confirm Your NPI Numbers
Your Type 1 NPI is your individual provider identifier. If you have been practicing, you already have one. Your Type 2 NPI is your organizational identifier, required if you are billing Medicare under your business name rather than your personal name.
Both are free and can be obtained through the National Plan and Provider Enumeration System. Type 1 NPIs are usually processed within a few days. Type 2 may take one to two weeks.
Step 2: Set Up Your PECOS Enrollment
PECOS is the Provider Enrollment, Chain, and Ownership System — CMS's online portal for managing your Medicare enrollment. You will need an EIDM account (Enterprise Identity Management) to access PECOS.
Create your EIDM account first, then link it to your NPI. This process involves identity verification and can take several days, so do not leave it for the last minute.
Step 3: Complete Your CAQH Profile
CAQH (Council for Affordable Quality Healthcare) is a credentialing database used by Medicare and most commercial payers. Think of it as a centralized professional profile that payers pull from during credentialing.
Your CAQH profile includes your education, training, work history, licensure, malpractice history, and practice information. Complete every field — even optional ones. Incomplete CAQH profiles are a leading cause of credentialing delays.
Re-attest your CAQH profile every 120 days. Set a calendar reminder. If your profile lapses, it can delay or disrupt active credentialing applications.
Step 4: Submit Your CMS-855I Application
The CMS-855I is the Medicare enrollment application for individual practitioners. If you are also enrolling your practice entity, you will need the CMS-855B (for organizations) as well.
You can submit through PECOS online or mail a paper application. Online is strongly recommended — paper applications take longer and are more prone to processing errors.
1. Key Sections of the CMS-855I
- Identifying information and NPI
- Practice location and contact information
- Licensure and certification
- Medical/professional school information
- Practice type and specialty
- Billing agency information (if using one)
- Reassignment of benefits (if billing through a group)
2. Common Pitfalls
- Missing or incorrect reassignment forms when billing through a group practice
- Address discrepancies between your application, NPI registry, and CAQH profile
- Forgetting to sign the application (yes, this happens frequently)
- Not understanding the difference between Part A and Part B enrollment
Step 5: Wait, Follow Up, and Respond Quickly
After submission, expect a 60 to 90 day processing window. During this time, CMS may send you requests for additional information. Respond within 30 days or your application will be denied.
Check your PECOS portal regularly for status updates. If you have not heard anything after 60 days, call the Medicare Administrative Contractor for your region to check on your application.
Part A vs. Part B: Know the Difference
Medicare Part A covers inpatient hospital, skilled nursing facility, and home health services. Part B covers outpatient services, including private practice OT.
Most OTPs starting a private practice need Part B enrollment only. If you plan to provide services in a SNF or through a home health agency under your own practice, you may need Part A enrollment as well. The application forms and processes differ.
The 2025 Policy Change for OTAs
An important update: CMS changed its supervision requirements for occupational therapy assistants in private practice under Medicare Part B. OTAs now require general supervision rather than direct supervision. This means the supervising OTR does not need to be physically present for every treatment session, opening new possibilities for COTAs working in private practice settings.
This is significant for practice owners who want to hire OTAs to expand their capacity.
Timeline Summary
1. Realistic Credentialing Timeline
- Weeks 1 to 2: Gather documents, confirm NPIs, create EIDM account
- Weeks 2 to 3: Complete CAQH profile
- Weeks 3 to 4: Submit CMS-855I through PECOS
- Weeks 4 to 16: Processing period with potential information requests
- Week 16 and beyond: Effective date assigned, begin billing
Your Next Step
Medicare credentialing is a process, not a mystery. Follow the steps, stay organized, and respond quickly to any requests. The timeline feels long, but remember — you can see cash-pay clients while credentialing is in process.
OT Connected has a full Insurance and Billing knowledge base section with articles on Medicare documentation, CPT codes, superbill templates, and credentialing checklists.
Join OT Connected and take the complexity out of Medicare credentialing.