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Guide

Getting Paid While Credentialing Is Pending: Oregon And The Western States

Waiting on credentialing? This guide explains when Oregon requires payment for covered care while an application is pending, which exclusions apply, and how other Western states compare. We prepare, submit and follow each application until the payer gives its written decision.

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Credentialing

In Oregon, once a PPO or managed care insurer has your complete credentialing application, it has 90 days to approve or reject it and must pay for covered care you deliver meanwhile. Washington, Arizona, New Mexico and Wyoming have versions with a condition deciding whether you get paid. California, Utah and Colorado set deadlines without back pay. Idaho, Nevada, Montana, Alaska and Hawaii have no state deadline or pay rule that we found.

The Oregon Rule, In Plain Terms

ORS 743B.454 starts the clock the day a health insurer receives your complete application, and the insurer has 90 days to approve or reject it. That span is the credentialing period, ending at the decision or day 90, whichever comes first.

Every covered service you provide during that period is payable. You can submit claims during or after the period. If you submit within six months after it ends, the insurer can’t deny them for timely filing.

The insurer may pay those visits at the rate it pays out of network providers. A 2025 amendment, House Bill 3242, changes one case: a clinician joining a group already in network with that insurer is paid the in network rate during the credentialing period. The group owes back the difference if the application is incomplete or the clinician isn’t approved, and the insurer must tell the clinician within 90 days if anything is missing.

Oregon counts an application as complete with everything the insurer requires, proof of a license from an Oregon health professional regulatory board, current DEA registration if you need one, and proof of professional liability coverage meeting the insurer’s requirements.

The date that matters is the day the insurer received your complete application, not the day you mailed or submitted it. Get that date in writing from each insurer and keep it with the file.

The rule covers insurers selling managed health insurance and PPO coverage. It excludes HMOs, and the Oregon Health Plan, which runs its own enrollment with retroactive rules under OAR 410-120-1260. It also excludes a clinician the insurer previously rejected or terminated for failing professional standards, after a chance to contest it before a peer panel. Our Oregon credentialing guide covers the payers one by one.

What The Law Leaves To You

A state rule like Oregon’s protects the dates. It doesn’t load you into insurer systems or say how insurers want claims.

Approval and in network billing are separate events. After approval, the contract must be executed and your record loaded into the insurer’s claims system, payment setup and directory. For a new provider’s first contract that often outlasts credentialing, and every insurer does it differently. Until you’re loaded, a claim can deny or process out of network and must be reworked.

Holding claims varies. Oregon lets you submit claims for the period during or after it, Arizona makes holding a condition of being paid back, and Washington pays once credentialing is complete. Either way, confirm with each insurer how it wants those claims and that your contract is loaded before switching billing over.

  • Record in writing when each insurer received your complete application.
  • Ask each insurer how it processes claims for the pending period, and note who said so.
  • Confirm the contract is executed and your record loaded before routine in network billing.
  • Track the six month window after the period ends, or your state’s equivalent.
  • Send each insurer one test claim before switching over.

How Oregon Compares Across The West

These are commercial insurance rules. Self funded employer plans and Medicare Advantage generally sit outside state insurance law, and Medicaid plans run their own enrollment, so confirm your plan type.

StateDecision DeadlinePaid For Care While Pending?What To WatchLaw
Oregon90 days from a complete applicationYes, for covered care from the day the complete application arrives until the decision or day 90. Out of network rate allowed; in network for a clinician joining an in network group.Claims can go in during or after the period, plus six months after it ends. HMOs and the Oregon Health Plan aren’t covered.ORS 743B.454, as amended by HB 3242 (2025)
Washington90 days from a complete application, with decisions averaging no more than 60Yes, once approved, at the contract rate: back to the application date when joining your group’s contract, or to a new contract’s effective date.Payment comes on completion, so plan to hold or rebill claims.RCW 48.43.750, 48.43.757
California60 days for mental health and substance use providers; 90 for others under AB 1041, in effect January 1, 2026, with a year for plans to comply.No. Neither law pays for care before the contract.The timelines cover credentialing, not contracting. Under AB 1041 the plan must activate you and tell you within 10 days of approval. Medi-Cal is separate.Health and Safety Code 1374.197, 1374.198; Insurance Code 10144.56, 10144.565
Arizona7 days to acknowledge and list anything missing, 60 to credential, and 30 from the complete application to load you for billingYes, at the in network rate, from the date on the insurer’s notice that your application is complete.Hold claims until you’re approved and your contract is fully executed, then file within a year of the date of service. Before treating a patient in a network facility, give written, dated notice with your name, the estimated cost and a statement that you aren’t yet credentialed or contracted. In effect since April 1, 2026.A.R.S. 20-3453, 20-3454, 20-3456 (SB 1291, 2025)
New Mexico30 days to decide and load you into payment systems and the directory, 45 when a file is flaggedIf the insurer decides or loads you late, services over 30 days after it received the complete application are paid at its standard rate or your group’s contract rate.Send requested documents on time, carry malpractice coverage and have no license sanctions.NMSA 59A-22-54, 59A-23-14, 59A-46-54, 59A-47-49 (SB 232, 2023)
WyomingReceipt notice in 7 days, incomplete notice in 30, decision in 60, for applications filed on or after July 1, 2025Only if a signed contract is in effect when you see the patient; then, once credentialed, you’re paid back to the date the insurer received your completed application.Get the contract signed early; care before it takes effect isn’t covered by this rule.W.S. 26-56-101, 26-56-102
ColoradoReceipt in 7 days, incomplete notice in 10, decision in 60. A 2026 amendment extended this from physicians to mental health and substance use providers and psychiatric nurses.No back pay. If the insurer misses the 7 day receipt notice, you’re treated as participating by day 53.From 2027, insurers must check yearly with behavioral health providers who haven’t billed in 12 months, and drop those who don’t answer two requests.C.R.S. 10-16-705.7, as amended by HB26-1002, effective August 12, 2026
Utah120 days after the insurer has all necessary informationNo.Nothing on loading or claims while pending.Utah Code 31A-45-304
Idaho, Nevada, Montana, Alaska, HawaiiNo state deadline foundNo state deadline or pay rule found; the insurer’s contract and policy decide.Nevada requires the state’s standardized credentialing form.Checked October 25, 2026

How long each insurer takes is separate. Our credentialing timeline guide lists what each payer publishes, by state.

Where We Come In

In our experience, these details often get skipped when the job is treated as filing applications and setting up accounts. They decide whether a new provider’s visits during the wait get paid.

With AdvanceAPractice they’re part of the work. When we credential a provider, we record the date each insurer received the complete application, ask how it wants pending claims, and confirm when the contract is loaded, so you know the day you can bill in network. If someone else handles your medical billing, we walk you or your biller through the same steps. You get answers about your own files, not a spreadsheet to decode alone.

Questions We Get

Can I See Insurance Patients In Oregon Before I’m Credentialed?

With a commercial insurer covered by ORS 743B.454, covered care after it receives your complete application is payable for up to 90 days while it decides. It may pay out of network rates unless you’re joining a group already in network with that insurer. HMOs and the Oregon Health Plan aren’t covered by this rule.

Should I Hold Those Claims Or Send Them?

It depends on the state and insurer. Oregon lets you send them during or after the credentialing period, Arizona requires holding them until you’re approved and contracted, and Washington pays once credentialing is complete. Ask each insurer how it wants those claims, and confirm your record is loaded before routine billing.

Is Credentialing Approval The Same As Being In Network?

No. After approval, the contract must be executed and your record loaded into the insurer’s claims and payment systems. California’s newer law makes the plan activate you and tell you within 10 days of approval; most states set no loading deadline.

What Counts As A Complete Application In Oregon?

Everything the insurer requires, plus proof of an Oregon license from a health professional regulatory board, current DEA registration if needed, and proof of professional liability coverage meeting the insurer’s requirements. The clock starts when the insurer receives all of it.

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Every credentialing package has a published price and a written scope, priced per insurer, and Monthly plans are available at the same total, with no interest or fees. This guidance comes with it: dates, claims and contract load, explained for your practice.

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Sources

Every fact here comes from the sources listed, read on the dates shown. This page covers payer operations, not legal advice. Laws and insurer policies change, so confirm the current rule first.