When it comes to medical billing, verifying a provider’s status isn’t just a formality—it’s essential. Submitting claims with inactive, uncredentialed, or improperly enrolled providers can lead to costly claim denials, compliance issues, and even audits. Whether you’re part of a solo practice or a large multi-provider organization, confirming each rendering provider’s status is a key step in maintaining a healthy revenue cycle.

In this guide, we’ll break down everything you need to know about verifying a provider’s status, including how to check for credentialing, NPI activation, Medicaid/Medicare enrollment, and commercial payer participation.

Why Verifying a Provider’s Status Is Critical for Clean Claims

Before you submit a claim to Medicaid, Medicare, or any commercial insurer, you need to ensure that the rendering provider is:

• Properly credentialed

• Actively enrolled with the payer

• Authorized to bill under the taxonomy and NPI listed

• Active on the date of service (DOS)

Failure to do so may result in:

• Denial codes such as “Rendering provider not active,” “Provider not recognized,” or “Provider not eligible”

• Payment delays or zero reimbursement

• Compliance red flags and audits

Steps for Verifying a Provider’s Status

🔹 Step 1: Confirm NPI Registration and Status

Start by confirming the provider’s National Provider Identifier (NPI) is valid and accurately linked to their name, taxonomy, and credentials.

How to check:

• Visit the NPPES NPI Registry

• Search by provider name or NPI number

• Confirm:

  • NPI is active

  • The taxonomy code is correct

  • Provider type (individual or organization)

  • Specialty matches the services billed

This is especially important for behavioral health providers like BCBAs, psychologists, and social workers.

🔹 Step 2: Verify Medicaid/Medicare Enrollment

If you’re billing Medicaid (e.g., Maryland Medicaid) or Medicare, the provider must be actively enrolled with the appropriate payer.

✅ For Maryland Medicaid:

Use the ePREP portal:

• Log into the Maryland Medicaid ePREP Portal

• Check provider enrollment status by NPI

• Ensure:

  • Enrollment is active and not expired

  • The provider is approved for the correct program type (PT27 for Mental Health Group, etc.)

  • Effective dates cover the Date of Service

📩 If corrections are needed, send an email to ” The Maryland Department of Health” : mdh.bhenrollment@maryland.gov

✅ For Medicare:

• Check enrollment via PECOS

• Confirm the provider is approved and active to render services

• Look at revalidation dates and group reassignment status

🔹 Step 3: Confirm Commercial Payer Credentialing

Every commercial insurance plan has its network and credentialing process. If your provider isn’t in-network, claims will either be denied or paid at out-of-network rates.

How to check with commercial payers:

• Log into the payer’s provider portal (e.g., Aetna, Cigna, BCBS)

• Call the provider services number listed on the back of the insurance card

• Ask:

  • Is this provider credentialed and active with your network?

  • What is their effective date and specialty designation?

  • Are there any restrictions or limitations?

🛑 If your provider is not credentialed, request an application or confirm if retroactive credentialing is allowed.

🔹 Step 4: Confirm Internal Group Affiliation

If the provider is billing under a group NPI, confirm:

• The provider is linked to the group in ePREP or PECOS

• The billing group has the correct taxonomy and provider type

• The rendering provider is authorized to bill under that group by the payer

Missing or incorrect group affiliation is a top cause of claim denials.

Best Practices for Verifying a Provider’s Status

• 🔄 Recheck status before onboarding or submitting the first claim

• 📅 Track revalidation and credentialing expiration dates

• 📥 Keep documentation on file (approval letters, NPI registry printouts)

• ✅ Create a verification checklist for new hires or newly added providers

• 🔐 Limit billing access until all credentials and statuses are confirmed

When to Verify a Provider’s Status

Let Taylor Prime Solutions Help with Credentialing & Claim Prep

At Taylor Prime Solutions, we assist ABA and behavioral health providers with more than just claims—we help you:

• Track and verify provider status

• Navigate credentialing with payers

• Avoid denials linked to inactive or unqualified providers

• Submit clean claims the first time

We’re not just billers—we’re your extended team. From verifying a provider’s status to handling complex denials and appeals, we ensure your claims are clean, compliant, and paid faster.

If your organization needs help with:

✅ Medical billing services
✅ Verifying provider credentials and enrollment
✅ Denial management and appeals
✅ Credentialing or pre-claim checks

📞 Call us today: 844-TAYLOR-9 (844-829-5679)
🌐 Visit: www.taylorprimesolutions.com
📧 Message us here

Verifying a provider’s status should be a standard part of your billing and compliance workflow. It saves time, prevents denials, and protects your practice from reimbursement delays. Don’t leave it to chance—make it a routine step in your operations.