How to Build a Credentialing Platform Like Medallion?

Key Takeaways

• For making a credentialing platform like Medallion, start by mapping the complete provider credentialing workflow before you select any technology.
• The platform should bring provider information and credential checks into one place. It should also make licensing and enrollment easier to manage.
• You also need secure connections with healthcare databases and verification sources so the data can be checked and updated.
• See how IdeaUsher can help you build a secure and scalable credentialing platform like Medallion.

To build a credentialing platform like Medallion, you need to automate provider onboarding, verify credentials directly against primary sources, manage licensing across multiple states, and streamline payer enrollment. If you plan to build a platform like this with IdeaUsher, you get a team that understands healthcare compliance along with software development. We can help you plan the right MVP and answer questions about NCQA requirements, data security, and healthcare integrations before development begins. 

Many startups across the United States have approached us to build credentialing platforms of their own. Healthcare founders keep spotting the same gap Medallion filled, and they want a partner who can build it right. That interest is why we wrote this blog. Let’s start!

Why Credentialing Is Becoming a Bigger Healthcare Operations Problem?

Credentialing was once treated mainly as a compliance task. Today, it is becoming a real operations and revenue problem. According to Grand View Research, the global market for credentialing software and services in healthcare was valued at USD 807.8 million and is projected to reach USD 1.42 billion by 2030, growing at a CAGR of 8.3%. The reason is simple: credentialing delays can affect provider activation, patient access, and revenue.

Source: Grand View Research

Onboarding Delays Slow Activation

A newly hired provider may be ready to work on day one, but they often cannot see insured patients until credentialing and payer enrollment are complete. This process can take 90 to 120 days, leaving organizations to pay salaries and overhead while the provider cannot generate reimbursable revenue.

Medallion-cited research found that roughly 80% of providers were dissatisfied with their organization’s credentialing process, with paperwork, complexity, and wait times among the main concerns.

Symplr is addressing this bottleneck through automation. Its symplr Provider software reports up to a 60% reduction in time spent on credentialing, recredentialing, and monitoring expirables. Its recently launched symplrCVO also combines payer enrollment services with an NCQA-certified primary source verification team, helping organizations connect these workflows.

Manual Credentialing Adds Work

Manual credentialing involves contacting multiple institutions, state boards, and databases. Teams also have to track documents, follow up with payers, and monitor expirations. Automation can bring much of this work into one system.

As provider networks grow, this workload becomes harder to manage manually.

Modio Health’s OneView platform addresses this by pulling provider details such as NPI numbers, DEA registrations, and state licenses from public and primary sources. Modio has also added multi-factor authentication and published a SOC 2 Type II attestation. Its managed service arm, Modio XCS, reports getting clients to their payer effective date in an average of 60 days compared with the industry standard of 120 days.

Credentialing Delays Affect Revenue

Slow credentialing can have a measurable financial impact. Data covered by Hospitalogy found that 69% of health systems, hospitals, and provider groups reported losing between $1,000 and $5,000 per provider, per day because of payer enrollment delays. Among organizations that could quantify the impact, one in five reported losing more than $1 million annually.

The impact also reaches patients. Providers stuck in credentialing cannot always be scheduled for insured patients, which can contribute to referral delays and longer appointment waits. For organizations expanding provider networks or telehealth services, a 90 to 120-day credentialing delay can slow growth and limit access to care.

What Are You Building When You Build a Medallion-Like Platform?

When you build a platform like Medallion, you are creating more than a basic credentialing tool. The goal is to build a connected provider operations system that keeps credentialing, enrollment, licensing, monitoring, and provider data working together. This helps healthcare teams manage the provider lifecycle from one place instead of switching between different tools.

1. Credentialing Is Just the Start

Many teams stop at verification: check the license, confirm the certification, and mark the provider as credentialed. But Medallion goes much further. Its platform includes workflows for provider enrollment, roster management, delegated credentialing, payer contract management, privileging, cross-state licensing, and ongoing monitoring.

DirectShifts approaches this from another angle. Its positioning suggests that credentialing is only part of the provider operations process. The broader lesson is simple: credentialing is the trigger, not the finish line. A platform should be designed to support the workflows that come after verification instead of adding them later.

2. Provider Data Powers the Platform

Every major workflow in a credentialing platform depends on the provider record. If that data is incomplete or out of sync, verification, enrollment, and monitoring will face the same problems. A provider record needs to track much more than a name and license number:

At scale, this provider record becomes the platform’s main asset. Medallion’s funding announcement stated that it supports approximately 1 million providers, or roughly 10% of the U.S. healthcare workforce, on its system.

3. Connecting Core Provider Workflows

Once the provider record exists, the challenge is keeping every workflow connected. A license renewal should update the provider record and trigger the right enrollment and monitoring actions. When these workflows use separate systems, teams end up managing multiple sources of truth.

Symplr followed a similar approach when it migrated its Cactus customer base to symplr Provider. The company reported adding more than 120 user-requested enhancements to bring application, verification, credentialing, privileging, enrollment, and monitoring into one provider data system.

Medallion reports more than 21 million primary source verifications and around 99.5% credentialing file accuracy. Its acquisition of Andros adds another layer, with Andros holding accreditation across 11 of 11 NCQA standards and processing roughly 300,000 credentialing files annually.

4. AI in Provider Operations

AI works best here as a way to remove repetitive work rather than replace credentialing specialists. EngineerBabu notes that manually checking seven to ten primary sources per provider can be reduced to under five minutes when APIs automate the searches and flag discrepancies for review.

AI Handles Repetitive Tasks

That human review remains important. Andros, now part of Medallion, says its approach keeps human-in-the-loop credentialing specialists involved alongside automated data extraction.

AI adoption in credentialing is still developing. Medallion’s industry survey found that only 12% of healthcare organizations’ AI investments currently involve credentialing. A Medallion-like platform therefore needs to balance automation with human oversight that compliance teams can trust.

What Problems Should a Modern Credentialing Platform Solve?

A modern credentialing platform should fix the gaps that slow providers down and create compliance risks. These include incomplete applications, scattered provider data, slow verification, payer-specific enrollment, expiring credentials, and repeated follow-ups. Each problem needs a focused workflow rather than a basic credentialing module.

1. Incomplete Provider Applications

A credentialing file is only as useful as the information submitted. Missing malpractice certificates, employment gaps, or signatures can keep an application pending for weeks. Industry analysis has found that more than 85% of applications contain an error or missing information.

A platform should use guided intake instead of static forms. Required fields can be validated before submission, and expired or missing documents can be flagged immediately.

2. Fragmented Provider Data

Provider information can still be spread across CAQH profiles, hospital files, payer portals, and HR systems, creating different versions of the same data. Medallion estimates that this duplication contributes to around $1.2 billion in annual redundant credentialing costs across payers.

A modern platform should treat the provider record as a single source of truth and keep that information connected across credentialing workflows.

3. Slow Primary Source Verification

Primary source verification confirms credentials directly with the issuing organization. NCQA requires it for medical licensure, board certification, DEA registration, and NPDB history. Manual verification means checking each source separately. API-based verification can make this process much faster. For example, CredyApp maintains connections with more than 6,000 primary sources, covering 95% of U.S. medical schools and providing real-time connections with all 50 state medical boards.

4. Payer-Specific Enrollment Workflows

Credentialing confirms that a provider is qualified to practice. Payer enrollment allows that provider to bill Medicare, Medicaid, and commercial health plans. Each payer can have different timelines, documents, and portals. CAQH’s 120-day re-attestation cycle provides some standardization but does not remove these differences. 

CMS Administrator Dr. Mehmet Oz also issued a directive requiring all 50 state Medicaid agencies to submit provider revalidation plans within 30 days. Verisys responded with a partnership with ID.me to help state Medicaid programs manage revalidation more efficiently. A platform therefore needs flexible payer workflows rather than treating every enrollment as the same form.

5. Expiring Credentials and Compliance Gaps

Credentialing continues after a provider is hired. Licenses, DEA registrations, and board certifications all need ongoing tracking and renewal. NCQA standards also call for continuous monitoring of areas such as licenses, sanctions, and exclusions. A missed expiration can quickly become a compliance issue. 

MedTrainer addresses part of this problem through NPDB automation, allowing teams to run National Practitioner Data Bank queries directly within the platform instead of relying on separate systems.

6. Repetitive Provider Follow-Ups

Credentialing teams often spend time chasing providers for missing or outdated documents. CAQH’s 120-day re-attestation requirement adds to this recurring workload. MedTrainer is addressing this with an AI-powered document intake system that classifies documents, extracts relevant data, and places it into the correct provider record. 

The company now supports more than 300,000 healthcare professionals across 15,000+ healthcare sites, backed by Telescope Partners and Vista Equity Partners. Automation at this scale can reduce the manual work involved in repeated document collection and provider follow-ups.

The Core Modules Behind a Medallion-Like Credentialing Platform

A Medallion-like credentialing platform needs more than a basic verification tool. Its core modules should work together to manage provider data, documents, credential checks, CAQH, payer enrollment, licensing, monitoring, and approvals. When these parts share the same provider record, healthcare teams can manage the full credentialing process from one connected system. 

1. Provider Data and Profiles

This is the foundation for every other module. A structured provider profile should store identity details, education, licenses, DEA registration, board certification, and malpractice history in one place. CAQH’s universal provider identifier is a key part of this data. A completed CAQH profile can be shared with more than 1,000 participating health plans instead of being entered separately for each payer. The platform should therefore treat the CAQH number as a core identifier that connects enrollment, monitoring, and committee workflows.

2. Credential and Document Management

Provider files can contain hundreds of pages across licenses, certificates, malpractice policies, and references. A platform should do more than store these documents. It should extract key details such as license numbers, issuing states, and expiration dates so they can be tracked automatically.

This removes the need for teams to repeatedly search through folders for documents that are about to expire.

3. Primary Source Verification

Primary source verification confirms credentials directly with the issuing authority. NCQA requires it for licensure, board certification, DEA registration, and NPDB history. Manual verification can involve seven to ten separate sources and take hours per provider. Direct API connections can reduce this to minutes. The module should also continue monitoring credentials after the initial verification rather than treating hiring as the end of the process.

4. CAQH Data Management

CAQH ProView acts as a shared database for many U.S. commercial payers. A platform’s CAQH module should pull information into the provider profile and push updates when details change. The main challenge is CAQH’s 120-day re-attestation cycle. Automated reminders can help providers complete their attestations on time and prevent an expired profile from delaying an otherwise complete payer application.

5. Payer Enrollment

Credentialing confirms that a provider is qualified to practice. Payer enrollment confirms that a specific payer allows the provider to bill. Since each payer can use different processes, the platform needs flexible workflows.

6. Licensing and Privileging

Licensing shows whether a provider can legally practice in a state. Privileging determines whether a hospital or facility allows them to perform specific procedures. Both workflows should be managed within the same platform. Multi-state licensing is increasingly important as telehealth expands. Medallion has also expanded into privileging by aligning its capabilities with Joint Commission standards and adding electronic privileging workflows and automated application submission to partner hospitals.

7. Ongoing Provider Monitoring

Credentialing continues after the initial approval. NCQA expects ongoing monitoring, including checks against state licensing boards, the DEA, OIG, SAM.gov, and NPDB. The platform should run these checks regularly and flag status changes as they happen. This helps teams catch expired or changed credentials before they become larger compliance problems.

8. Roster and Network Management

Payers and large provider networks need an accurate list of participating providers across their systems. ProCredEx took a different approach by creating a blockchain-based exchange where organizations such as National Government Services, Spectrum Health, and Accenture could share verified credential data. The company reported reducing a credentialing lifecycle from four to six months to 18 to 21 days for organizations using its exchange model.

ProCredEx later joined the Synaptic Health Alliance’s provider data blockchain initiative, which focuses on keeping provider directory information accurate across member health plans.

9. Credentialing Committee Workflows

Many organizations still use committees for final credentialing approval. A platform can digitize this process by distributing application packets, tracking reviews, and managing different approval chains. Silversheet built its platform around committee management, digital privileging templates, and peer-reference tracking. 

AMN Healthcare acquired the company in 2019 in a deal reported to be worth roughly $55 million, bringing committee-driven credentialing into its broader healthcare workforce solutions.

How Should Primary Source Verification Work in Credentialing Platforms?

Primary source verification should use a layered approach. APIs handle routine checks against state boards, registries, and certification bodies, while human reviewers handle flagged cases. The goal is not to remove people from the process. It is to reduce manual lookup work while keeping the oversight NCQA expects. This balance helps platforms scale without losing accuracy.

1. State Medical Board Verification

Each state medical board has its own database and update process. The platform should connect to the relevant boards and verify that a license is active, unrestricted, and free of disciplinary action. This becomes more important as multi-state practice grows. The Interstate Medical Licensure Compact covers more than 40 U.S. states and one territory, allowing physicians to use an expedited licensing path while each state still issues its own license. A platform must therefore support providers with licenses across multiple states.

2. DEA Verification

Providers who prescribe controlled substances need an active DEA registration. The platform should verify it against the DEA National Registration System rather than relying on submitted copies. It should also track renewal dates and confirm the drug schedules the provider is authorized to prescribe.

3. Board Certification Verification

Board certification should be verified directly through the American Board of Medical Specialties or ABMS. ABMS has 24 Member Boards and reported more than 1,025,104 certified physicians and medical specialists, an increase of more than 27,000 from the previous year.

The platform should confirm that the certification is valid and matches the provider’s specialty and subspecialty.

4. NPDB Checks

The National Practitioner Data Bank or NPDB contains information on malpractice payments, adverse licensing actions, and clinical privilege restrictions. NCQA requires NPDB queries as part of standard primary source verification. A new NPDB report should trigger a review instead of waiting for the next two- or three-year recredentialing cycle.

5. OIG and SAM Screening

Providers also need to be checked against federal exclusion lists, including the OIG List of Excluded Individuals and Entities and SAM.gov. Platforms such as HealthStream’s CredentialStream combine automated verification for licenses, certifications, sanctions, and exclusions. Recurring checks are important because a provider can be added to an exclusion list after initial credentialing.

6. Automated Discrepancy Detection

A verification query is only useful if the platform can compare the result with the provider’s submitted information. It should flag issues such as license number errors, mismatched certification dates, or other data differences. Medallion uses automated QA technology to compare primary source documentation with provider profiles and route discrepancies for review. This helps automation improve accuracy instead of simply moving errors through the system faster.

7. Human Review for Exceptions

Automation should not approve every result without review. NCQA expects accountability for credentialing decisions, making human oversight an important part of the workflow. The Andros CVO, now part of Medallion, uses human-in-the-loop credentialing specialists alongside automated data extraction. The platform can handle 90-plus percent of clean cases automatically while routing exceptions such as expired documents, name mismatches, or employment gaps to specialists.

8. Creating an Audit-Ready Record

Every verification should create a timestamped record showing what was checked, which source was used, and when it was verified. This provides evidence during NCQA or payer reviews. IntelliCentrics focuses heavily on this audit-ready approach. Its SEC3URE platform holds NCQA CVO certification across all 10 of 10 verification service categories, and monitors credentialed professionals across more than 10,000 locations of care.

At scale, this documentation becomes essential because organizations need to show not only that credentials were verified, but also when and how the verification happened.

How to Build a Credentialing Platform Like Medallion?

To build a credentialing platform like Medallion, start by creating a unified provider record and mapping the full credentialing workflow. Add primary source verification, CAQH management, payer enrollment, licensing, monitoring, and AI-powered automation to reduce manual work. The platform should also support secure healthcare integrations, continuous compliance checks, and scalable workflows for different provider networks. 

1. Map the Provider Lifecycle First

Building a credentialing platform starts with mapping the provider journey from application and primary source verification to committee review, payer enrollment, privileging, and recredentialing. Every design decision should follow this workflow. The process is not always linear. A provider may be in payer enrollment while also going through PSV for a license renewal. The platform therefore needs to track multiple workflow states for the same provider.

NCQA Sets the Cycle

NCQA requires providers to be recredentialed every 36 months from their last approval. The process should begin 90 to 120 days before expiration, which means the platform needs a recurring-cycle engine rather than a one-time onboarding flow.

2. Build a Unified Provider Record

A unified provider record keeps every credential, license, certification, document, and status update in one profile. Other modules such as PSV, payer enrollment, and privileging can then read from and update the same record instead of using separate spreadsheets and portals.

Make CAQH Part of the Model

CAQH ProView has more than 1.6 million providers and roughly 1,000 health plans and healthcare organizations using it to share provider data. Providers must also re-attest every 120 days. For a new platform, syncing with CAQH is usually more practical than trying to replace it. A CMS audit found that nearly half of Medicare Advantage online provider directory data could be inaccurate, showing why a connected provider record matters.

At minimum, the provider schema should include NPI, DOB, encrypted SSN, education, training, state licenses, DEA details, board certification, five-year malpractice history, and document expiration tracking.

3. Automate Primary Source Verification

Automated PSV connects directly with sources such as state medical boards, DEA, ABMS, NPDB, OIG, and SAM.gov. This removes much of the manual lookup work credentialing teams handle today. NCQA has also tightened verification timelines. Its updated standards reduced the PSV window from 180 to 120 days for Credentialing Accreditation and from 120 to 90 days for Credentialing Certification.

Add Recurring Monitoring

NCQA now requires monthly checks against OIG exclusions, SAM.gov federal debarment records, and state board disciplinary actions. These checks need to run automatically for every credentialed provider. CertifyOS reports more than 600 direct primary source integrations and says over 90% of PSV elements are completed without manual intervention. It also holds NCQA CVO Certification across all 11 credentialing evaluation elements, a designation held by fewer than 100 organizations.

Medallion uses a similar automated PSV approach through its NCQA-certified CVO. The platform should log every verification method and timestamp while routing discrepancies to human reviewers.

4. Connect Payers and Healthcare Systems

A credentialing platform needs to connect with CAQH ProView, PECOS, state Medicaid portals, commercial payer systems such as Availity, and FHIR-based APIs. These integrations vary by payer and should not be treated as one standard connection.

Build Around Payer Tiers

• Medicare and Medicaid: PECOS and state Medicaid portals support structured submissions and status checks.
• Major commercial payers: UnitedHealthcare, Aetna, and BCBS affiliates often use platforms such as Availity for semi-automated submissions and status polling.
• Regional and smaller payers: Many still use payer-specific portals with limited API support.

CMS’s Interoperability and Prior Authorization Final Rule (CMS-0057-F) requires impacted payers to implement four FHIR-based APIs, with API development compliance generally required by January 1, 2027. This makes a FHIR-ready integration layer important for future-proofing the platform.

5. Add AI to Manual Workflows

AI can help identify data discrepancies, extract information from scanned documents through OCR, prioritize files for review, and route routine cases. It should support PSV rather than replace it because NCQA still requires verification against the actual issuing authority.

Focus AI Where It Helps

Medallion found that only 12% of healthcare AI investment currently touches credentialing. CAQH has estimated that automating provider data management could save around $2.1 billion annually in administrative costs. Medallion’s acquisition of Andros and its CredAlliance initiative show where the market is heading. CredAlliance aims to verify provider credentials once and reuse them across participating payer networks. Forbes reported that this could address a substantial portion of the roughly $1.2 billion in redundant credentialing spend across payers.

The bigger opportunity is not simply verifying faster. It is avoiding repeated verification of the same information.

6. Design for Continuous Compliance

Continuous compliance means the platform keeps checking provider credentials between recredentialing cycles. This includes monthly exclusion screening, license monitoring, and automatic recredentialing triggers. This helps catch issues early and prevents expired credentials from disrupting provider operations.

Recurring Checks to Automate

• Monthly OIG exclusion checks
• Monthly SAM.gov debarment checks
• Monthly state board disciplinary and license checks
• Continuous license expiration tracking

Compliance is also expanding into privileging. Medallion has added electronic privileging workflows aligned with Joint Commission standards and automated submission to partner hospitals.

The rules engine should therefore support new monitoring and compliance requirements without requiring a complete rebuild.

7. Scale From MVP to Enterprise

An MVP should start with a focused use case, such as provider records and PSV for one specialty or state. Payer enrollment, multi-state licensing, and privileging can then be added as volume and revenue grow. This approach keeps the initial development cost lower and lets you validate the workflow before adding more complex features.

Plan for Enterprise Scale

Smaller organizations typically pay around $15 to $50 per provider per month for credentialing software with moderate automation. Larger health systems often move toward enterprise licensing and volume-based pricing once they reach a few hundred providers. The same gradual approach applies to certification. 

Fewer than 100 organizations currently hold NCQA CVO Certification across all 11 credentialing evaluation elements, making it a useful enterprise benchmark rather than an MVP requirement.

How CAQH and Payer Enrollment Fit Into the Credentialing Platform?

CAQH and payer enrollment are two connected layers of a credentialing platform. CAQH provides standardized provider data, while payer enrollment uses that data to submit applications and track approval with individual payers. They should remain separate workflows because CAQH follows its own update cycle, while each payer has its own enrollment status and timeline.

1. Importing Provider Data From CAQH

The platform should pull provider data from CAQH through its API instead of making providers enter the same information again. This reduces duplicate work and lowers the risk of outdated or incorrect data. CAQH’s VeriFide provides a useful benchmark. CAQH reports that it can return about 98% of initial provider files within 14 days, with around 98.5% accuracy and completeness. The pilot included Aetna, Blue Cross Blue Shield of Michigan, and CareFirst BlueCross BlueShield.

2. Keeping Provider Profiles Current

Provider data should not be treated as static. The platform needs to track changes to licenses, malpractice coverage, board certification, and practice information.

Practice locations and hours also matter because provider directory accuracy is now a federal compliance issue, not just a service concern.

3. Re-Attestation Workflows

The platform should regularly ask providers to confirm their CAQH data. CAQH requires ProView re-attestation every 120 days for participating health plans. The Consolidated Appropriations Act also requires certain provider directory information to be re-verified every 90 days. These are separate requirements, so the platform should run them as two scheduled workflows with separate timelines.

4. Payer Application Tracking

The platform should track every payer application separately because providers may have several applications running at the same time.

This approach is also recommended in EngineerBabu’s credentialing platform guide. Tracking each payer relationship separately prevents multiple applications from being reduced to one confusing status.

5. Enrollment Status Management

Once applications are tracked, the platform should manage notifications, escalations, and stalled applications. Medallion’s payer enrollment product focuses on giving teams step-by-step visibility into application progress instead of requiring manual payer follow-ups. A useful status system should show more than a label. It should also show how long an application has been pending and what is blocking it, such as missing documents or payer questions.

6. Payer-Specific Requirements

Payers can require different documents, formats, and submission methods. The platform therefore needs workflows that can handle these differences. Verifiable reports that about 97% of its verifications are automated, with millions processed each month. Its NCQA-certified in-house team has more than 60 years of combined credentialing experience and handles exceptions that automation cannot resolve.

7. Automating Payer Follow-Ups

The platform can automatically check stalled applications and send updates instead of requiring staff to email or call payers manually. HealthStream’s CredentialStream provides examples of this direction. Its privileging solution received a patent in August 2024 for smart logic that evaluates provider qualifications against a privileging library.

Separately, HealthStream partnered with Verisys to launch Network by HealthStream, which continuously updates practitioner data across payer systems and supports payer credentialing, network adequacy checks, provider directory updates, and contract management. This moves payer workflows toward continuous data updates instead of manual follow-ups.

Where Can AI Replace Manual Credentialing Work?

AI can replace manual credentialing work when tasks are repetitive, document-driven, and based on clear patterns. It can extract license details, compare provider data, flag mismatches, route files, and monitor credentials. However, AI should not replace primary source verification or final human decisions. NCQA still requires credentials to be confirmed directly with the issuing authority.

1. AI-Powered Provider Data Extraction

AI can read licenses, diplomas, and malpractice certificates and extract fields such as name, license number, issue date, and expiration date. This removes manual data entry and supports the automation that follows. Incredable, a credentialing provider under Intiva Group, launched an AI Document Extractor that reads and verifies provider data from uploaded documents. 

It identifies license types, specialties, and facility affiliations and maps the information into the correct provider profile fields. Unlike basic OCR, it attempts to understand the document and where each value belongs.

2. Intelligent Document Processing

Intelligent document processing goes beyond extraction by identifying the document type and routing it to the correct part of the provider file.

This prevents documents from sitting in unsorted folders and helps reduce missed or expired credentials.

3. AI-Assisted Profile Completion

AI can use existing CAQH ProView data to pre-fill provider profiles instead of asking providers to enter the same information again. Education, work history, and malpractice details can be carried into the platform. A confidence score can also flag uncertain fields, such as unusual date formats or specialty names, for human review. This confidence-based approach is safer than automatically accepting every extracted value.

4. Automated Provider Outreach

AI can send reminders when documents are missing, credentials are expiring, or re-attestation is due. It can also escalate cases when providers do not respond. Andros, an NCQA-certified credentials verification organization acquired by Medallion, uses a structured escalation process. 

When its algorithms cannot resolve a discrepancy, trained credentialing professionals contact the provider or facility at least three times before treating the item as stalled. This shows how automation can handle routine outreach while humans handle unresponsive or complex cases.

5. Credential Discrepancy Detection

AI can compare provider-reported information with primary source data and flag issues such as suspended licenses, undisclosed malpractice claims, or expired certifications. Andros uses data-matching logic to identify missing information and issues involving malpractice, licensure, or sanctions before committee review. The company reports data verification across more than 8 million providers and about 300,000 credentialing actions in one year across 200+ networks in all 50 states.

6. Intelligent Task Routing

AI can prioritize which credentialing file a specialist should review based on deadlines, exceptions, or billing needs. This becomes more important with NCQA’s tightened verification windows. A routing system can move a provider nearing a payer deadline ahead of a newly submitted file, helping teams focus on the most urgent cases.

7. License and Credential Monitoring

Automated monitoring checks whether licenses, DEA registrations, and board certifications remain valid between recredentialing cycles. NCQA’s current standards require monthly checks against OIG exclusion lists, SAM.gov federal debarment records, and state medical board disciplinary actions for credentialed providers. Automating these checks makes ongoing monitoring more practical across large provider networks.

8. Human-in-the-Loop Review

AI should route exceptions to trained specialists instead of making the final credentialing decision. NCQA standards also require organizations using automated verification sources to confirm at least annually that the source is performing PSV correctly. The strongest model is automation for routine cases and human review for exceptions.

Andros follows this approach by using specialists when algorithms identify ambiguity or mismatches. Every automated action should also leave a documented trail with the method, source, and timestamp for later committee or audit review.

The Healthcare Systems Your Credentialing Platform Must Connect

A credentialing platform should connect with CAQH, NPPES, NPDB, state medical boards, OIG, SAM.gov, payer portals, EHR/EMR systems, HRIS platforms, and internal provider systems. These integrations bring provider data into one place, support primary source verification, track payer enrollment, monitor exclusions and licenses, and keep credentialing information synced across healthcare operations. 

1. CAQH

CAQH ProView acts as a shared provider data source. Providers enter education, work history, licenses, and malpractice information once and authorize health plans to access it. More than 1.6 million providers and roughly 1,000 health plans and healthcare organizations use ProView. Providers must re-attest every 120 days.

The platform should use the CAQH API to pull authorized provider data on a schedule. CAQH’s VeriFide is another useful benchmark. It is designed to return about 98% of initial provider files within 14 days, with around 98.5% accuracy and completeness.

2. NPPES

The National Plan and Provider Enumeration System (NPPES) is the CMS registry that assigns National Provider Identifiers. The NPI acts as a key identifier across payers, NPDB, state boards, and other systems. NPPES contains more than 9 million NPI records. CMS says a completed electronic NPI application can typically be processed within about 10 days, and obtaining an NPI is free.

The platform can use the NPPES public API to validate NPIs and check provider taxonomy and practice addresses against submitted information.

3. NPDB

The National Practitioner Data Bank or NPDB stores malpractice payment history and adverse licensing, clinical privilege, and disciplinary actions. Hospitals must query the NPDB for new medical staff applicants and existing staff at least every two years. Credentialing platforms can also use Continuous Query, which provides notifications within one business day when a new report is received.

4. State Medical Boards

State medical board integration is more complex because there is no single national licensing system. There are more than 50 state licensing authorities, each with different data formats, update schedules, and API availability.

This is why automated PSV should always be evaluated by asking which states are automated and how states without APIs are handled.

5. OIG and SAM

The OIG LEIE and SAM.gov databases show whether providers are excluded from federal healthcare programs. Screening both is important for organizations billing Medicare or Medicaid. The LEIE contains tens of thousands of excluded individuals and entities and is updated monthly. SAM.gov data updates daily. Federal guidance supports monthly screening of both. Missing an excluded provider can result in civil monetary penalties reaching tens of thousands of dollars per billed item or service.

6. Payers and Health Plans

Payer connectivity turns credentialing into revenue readiness. A provider cannot bill a health plan until that payer’s enrollment process is complete. Medicare and Medicaid use PECOS and state Medicaid portals. Major commercial payers often use aggregators such as Availity, while smaller regional payers may require manual portal submissions.

Medallion’s payer enrollment product brings these workflows together and tracks submission status, expected turnaround, and effective billing dates in one view.

7. EHR and EMR Systems

EHR and EMR integration sends credentialing status into clinical systems so providers can be scheduled, referred, and included in claims after activation. symplr’s Directory product consolidates provider data and syncs it with EHR systems such as Epic. After integrating IntelliCentrics, symplr’s Access Management solution manages roughly 3 million vendor and provider check-ins annually and is used by 21 of the top 25 health systems in the country.

8. HRIS Platforms

HRIS integration keeps credentialing aligned with employment status. Providers who are inactive or terminated should not remain in open credentialing workflows. MedTrainer syncs daily with Workday, UKG, Paycor, and Dayforce. It pulls employment status, location, department, position, and hire and termination dates and can automatically assign credentialing documents to new providers. It also performs monthly exclusion checks across 40+ databases, including OIG and SAM.

9. Internal Provider Systems

Internal systems such as practice management, scheduling, and custom provider databases can be harder to integrate because they may not offer clean APIs. Platforms can use webhooks, scheduled batch exports, or bidirectional APIs based on the organization’s needs. The key is keeping the credentialing platform’s provider record as the single source of truth so other systems do not develop conflicting data.

What Does It Cost to Build a Credentialing Platform Like Medallion?

Building a credentialing platform like Medallion can cost around $75,000–$157,000, depending on provider data architecture, PSV and CAQH integrations, payer connections, AI automation, monitoring, security, and enterprise workflows. A focused MVP can start with fewer integrations and features, while a full-scale platform needs stronger compliance, automation, and multi-system connectivity. 

1. Provider Data Architecture

Estimated cost: $8,000 – $18,000

This covers the provider record schema, document vault, expiration tracking, and deduplication. The data model should also support versioning so teams can see what a provider record looked like when a credentialing decision was made. It should also make it easy to retrieve and audit provider information whenever needed. 

2. PSV Integrations

Estimated cost: $15,000 – $30,000

PSV integrations vary by source. Some state boards offer APIs while others require web automation or manual checks. A typical source integration costs around $1,000–$3,000. A complete setup may include state boards, DEA, ABMS, NPDB, OIG, and SAM.gov. Baton Health built a Universal Primary Source that combines license and credential data into one query instead of separate state lookups. 

Baton has raised $8.75 million in seed funding and expanded its partnership with The Clinic by Cleveland Clinic to support physician licensing and compliance verification across all 50 states.

3. CAQH Integration

Estimated cost: $6,000 – $12,000

CAQH ProView integration includes API approval, provider authorization, data imports, and the 120-day re-attestation cycle. A two-way sync can cost more because the platform must also push provider updates back to CAQH. This helps keep provider information accurate and reduces duplicate data entry across workflows. 

4. Payer Integrations

Estimated cost: $10,000 – $20,000

CMS’s Interoperability and Prior Authorization Final Rule requires impacted payers to implement FHIR-based APIs, with compliance generally required by January 1, 2027. Building the integration layer around FHIR early can reduce future rework.

5. AI Automation

Estimated cost: $10,000 – $25,000

AI costs depend on the approach. Using an existing document-extraction API is cheaper than developing custom models for discrepancy detection. Start with document extraction and classification. Add discrepancy detection and intelligent task routing later when enough production data is available for tuning.

6. Monitoring Infrastructure

Estimated cost: $6,000 – $12,000

This covers recurring jobs for monthly OIG and SAM.gov checks, state board monitoring, and license expiration tracking. NPDB Continuous Query costs $2 per practitioner per year and provides notification within one business day when a new report is received.

7. Security and Compliance

Estimated cost: $8,000 – $15,000

This includes encryption, role-based access, audit logging, SOC 2 preparation, vulnerability testing, and penetration testing. These controls are essential for a platform handling provider PHI and Social Security numbers. This also helps build trust with healthcare organizations during security and compliance reviews. 

8. Enterprise Workflow Development

Estimated cost: $12,000 – $25,000

Enterprise workflows support multi-facility committee reviews, delegation agreements, role-based dashboards, and custom reporting. RLDatix acquired Verge Health and brought its Converge platform into its broader suite. At the time, Verge served about 900 healthcare organizations and 500,000 users, showing how credentialing can become part of a larger governance and compliance platform.

9. Total Estimated Cost to Build

The total estimated cost to build a credentialing platform like Medallion is $75,000–$157,000. This range covers the core data architecture, PSV and CAQH integrations, payer connections, AI automation, monitoring, security, and enterprise workflows needed for a production-ready platform. 

This estimate includes the security, compliance, integrations, and enterprise workflows needed for a production-ready credentialing platform, not just the basic feature set.

Build a Custom Credentialing Platform With IdeaUsher

You can build a secure and scalable custom credentialing platform with IdeaUsher that brings provider data, PSV, payer enrollment, AI automation, and compliance workflows into one system. Our team has 500,000+ hours of coding experience and includes ex-MAANG and FAANG developers who can help turn your credentialing workflow into a production-ready platform.

Healthcare Data and Integration Architecture

We build integration layers that connect CAQH, NPPES, NPDB, state medical boards, payers, EHRs, and HRIS platforms. This keeps provider data connected and available across the credentialing workflow. The architecture can also be designed to support new integrations as your platform grows.

Credentialing and PSV Automation

We can automate provider onboarding, document processing, primary source verification, license checks, and payer enrollment workflows while keeping human review for exceptions. This helps reduce repetitive work while maintaining the oversight required for sensitive credentialing decisions.

AI-Powered Healthcare Workflows

AI can handle repetitive tasks such as document extraction, discrepancy detection, profile completion, provider outreach, and task routing. This helps credentialing teams spend less time on manual work. Human reviewers can remain involved when the system detects unclear or complex cases.

Secure Provider Data Infrastructure

We design secure infrastructure with encryption, role-based access, audit trails, and compliance-focused data handling to protect sensitive provider information throughout the platform. This creates a stronger foundation for working with healthcare organizations and sensitive provider records.

Conclusion

Building a credentialing platform like Medallion requires more than automating provider verification. You need a connected system for provider data, PSV, CAQH, payer enrollment, licensing, monitoring, AI workflows, and secure integrations. Start with a focused MVP and expand as your provider network grows. With the right architecture, automation, and compliance controls, you can create a scalable platform that simplifies credentialing and provider operations. 

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