CAQH vs. PECOS: The Definitive Guide for Medical Practice Managers

If you work in healthcare administration, your life is governed by acronyms. NPI, TIN, taxonomy codes, CPT... the list never ends.

But two acronyms stand above the rest when it comes to getting paid: CAQH and PECOS.

For new Practice Managers (and even seasoned veterans), distinguishing between these two systems can be a source of constant frustration. They ask for similar information, yet they don't talk to each other. They have different deadlines, different login requirements, and different consequences if you ignore them.

Here is the definitive guide to understanding the difference between the commercial and federal gatekeepers of your revenue.

1. The Red Corner: CAQH (The Commercial Standard)

What is it?

CAQH (Council for Affordable Quality Healthcare) ProView is essentially the "Common App" for the medical industry.

Who uses it?

Almost all commercial payers. Aetna, BlueCross BlueShield, Cigna, UnitedHealthcare, and many regional plans use CAQH as their primary data source.

How it works:

Think of CAQH as a digital filing cabinet. You upload a provider's CV, license, malpractice policy (COI), and education history once. Then, you grant payers permission to access that cabinet. Instead of filling out 20 different applications for 20 different insurance companies, they all download the data from your CAQH profile.

The Catch: The 120-Day Rule

This is where practices lose money. CAQH requires you to "Re-Attest" (confirm your data is accurate) every 120 days.

· If you forget to click that button, your profile goes "inactive."

· Payers stop downloading your data.

· Pending credentialing applications stall.

· Result: Delays in enrollment and billing.

2. The Blue Corner: PECOS (The Federal Gatekeeper)

What is it?

PECOS (Provider Enrollment, Chain, and Ownership System) is the digital fortress for Medicare.

Who uses it?

CMS (Centers for Medicare & Medicaid Services). If you want to bill Medicare Part B, order DME (Durable Medical Equipment), or refer patients for Medicare-covered services, you must be in PECOS.

How it works:

Unlike CAQH, which is just a data repository, PECOS is a legal enrollment system. It links the individual provider (NPI Type 1) to the group practice (NPI Type 2/Tax ID). It is heavily focused on fraud prevention, so it asks detailed questions about ownership, adverse legal actions, and banking information.

The Catch: The 5-Year Revalidation

Medicare doesn't nag you every quarter like CAQH. instead, they require a full Revalidation every 5 years.

· The Trap: Because 5 years is a long time, people forget.

· CMS will send a notice 2-3 months prior. If you miss that window, they deactivate billing privileges immediately.

· Result: Medicare stops paying claims instantly, and reinstatement can take months.

The "Connectivity Myth"

The biggest mistake we see Practice Managers make is assuming these systems are connected.

They are not.

If you update Dr. Smith’s new malpractice policy in CAQH, Medicare does not know.

If you update Dr. Smith’s home address in PECOS, Aetna does not know.

You must treat these as two separate, parallel tracks. Every time a provider’s information changes (new license, new address, new insurance), you have a "Double Duty" obligation to update both portals independently.

How to Manage Without Going Crazy

Managing CAQH attestations for 10 providers means 40 deadlines a year. Managing PECOS revalidations adds another layer of complexity on a 5-year cycle.

If you are trying to track this on a whiteboard or a spreadsheet, you are playing a dangerous game.

1. Centralize Your Dates: Use a platform that tracks both Commercial and Medicare deadlines in one view.

2. Automate Attestations: Use software that reminds you before the 120-day CAQH window closes.

3. Single Source of Truth: Keep your documents (licenses, COIs) in a central digital library so you can quickly upload them to both CAQH and PECOS without searching through emails.

CAQH and PECOS are the twin pillars of your practice's cash flow. One feeds your commercial revenue; the other protects your federal revenue.

Understanding the difference isn't just "nice to know"—it is an essential survival skill for the modern medical practice.

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