As a pharmacist and pharmacy owner, you are one of the most trusted healthcare experts in your community. You perform clinical interventions, manage chronic diseases, and provide life-saving advice every single day.

And you do almost all of it for free.

I’ve been there. I remember the deep frustration of knowing I could solve a patient’s medication problem, but having no way to bill for my time. Why? Because in the eyes of medical payers, a pharmacy is a “store,” not a “provider.”

The key to changing that—to unlocking all the new pharmacy revenue streams we talk about—is a single, intimidating word: Credentialing.

I won’t sugarcoat it: credentialing is a mountain of paperwork. It’s the single biggest barrier for pharmacy owners, and it’s where most give up.

But here is the truth: It is a one-time mountain. And on the other side is a more sustainable, profitable, and professionally satisfying business. This guide will be your map to the summit.

What Is Credentialing (And Why Is It Different Than Dispensing)?

You are already credentialed with PBMs (Express Scripts, Caremark, etc.). That process allows you to get paid for a product (the pill).

Credentialing for medical services is a completely different system. It is the formal process that medical payers (like Medicare, Medicaid, and Blue Cross) use to verify your identity, license, education, and qualifications.

Once you are credentialed, you are “in-network” as a provider. This is the only way you can submit a medical claim (on a CMS-1500 form) and get paid for your clinical services.

In short: No credentialing, no medical billing.

This is the essential first step we cover in our foundational article, The Pharmacist-Owner’s Guide to Medical Billing & Reimbursement. You simply cannot bill for MTM, POCT, or clinical vaccines without it.

The Pharmacist’s Credentialing Toolkit: What to Gather First

Before you fill out a single form, get your documents in order. This will save you weeks of back-and-forth.

• Your Individual NPI (Type 1): You, the pharmacist, need an individual National Provider Identifier. This is separate from your pharmacy’s NPI.
• Your Pharmacy’s NPI (Type 2): This is the NPI for your organization.
• Your Pharmacy’s EIN: Your federal Tax ID number.
• State Pharmacy License: For your pharmacy and for each pharmacist who will be billing.
• Malpractice Insurance: Your Certificate of Insurance (COI) with minimum coverage (typically $1M/$3M).
• Your CV/Resume: A detailed history of your education and work experience.
• Diplomas & Certifications: Copies of your PharmD, residency, or any pharmacist certification (like BCPS, BCGP, etc.).
• Medicare Enrollment Forms: (More on this in a second).

A 3-Step Action Plan to Get Credentialed

Don’t try to boil the ocean. Follow this order.

Step 1: Medicare (The Big One)

Start with Medicare. Many private payers will follow Medicare’s lead.

• Why? This is your key to billing for Medicare Part B services like vaccines (Flu, COVID, Pneumonia), Diabetes Self-Management Training (DSMT), and “incident-to” services.
• How? You will use the CMS-855B form to enroll your pharmacy entity as a “Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)” supplier and/or a “Mass Immunization Roster Biller.” This is the most common “on-ramp” for pharmacies.
• The Wait: This process is not fast. Expect it to take 60-120 days. You will get a Medicare Provider Transaction Access Number (PTAN) once approved.

Step 2: State Medicaid

Next, enroll with your state’s Medicaid program.

• Why? This is often the only way to get paid for specific pharmacy services like MTM or tobacco cessation for your Medicaid patients. Many states are expanding their definition of “provider” to include pharmacists, but you must be enrolled.
• How? Each state has its own online portal and application. The process is similar to Medicare: you are enrolling your pharmacy as an organization and linking your individual pharmacists to it.

Step 3: Private Payers (The “Wild West”)

This is the hardest part, and where the most frustration happens.

• The Problem: Most private payers (Aetna, Cigna, BCBS) do not have a clear “box” for a pharmacist or consultant pharmacy to check. Their systems are built for doctors and clinics.
• The “In”: You often have to apply as an “ancillary provider,” a “DMEPOS provider,” or under a similar category. When you call, do not ask, “How do I credential a pharmacist?” Ask, “How do I enroll my pharmacy as a new provider to bill for preventative services and medical supplies?”
• A Potential Shortcut (CAQH): The “Council for Affordable Quality Healthcare” (CAQH) has a central database called ProView. Many private payers use this to pull your credentialing info. Filling this out once can save you from filling out 10 different applications.

The Honest Truth: Why This Is So Hard for Us

As I went through this process, I realized the system isn’t just complex—it’s not built for us.

When you apply, payers get confused. “Are you a clinic? Are you a DME company? Are you a consultant pharmacist?” They will try to put you in a box you don’t fit. You will likely get rejected.

This is normal.

This is why the process takes so long. A denial is often just the start of the conversation. It requires persistent follow-up, phone calls, and explaining your value as a provider of pharmacy services.

A Pharmacist’s Perspective: My time as an owner was my most valuable asset. I had to decide: Am I going to spend the next 10 hours on hold with an insurance company, or am I going to spend it with a patient?

This is the “DIY vs. Partner” decision. You can do this yourself. But it will take 90-180 days and countless hours of administrative work. Many owners find that partnering with a credentialing and billing pharmacy service (like RxBB) is the best investment they can make. We take the paperwork nightmare off your plate so you can get back to your patients.

Credentialing Is the Key

Don’t let the paperwork stop you from building a modern, profitable pharmacy.

Credentialing is the boring, frustrating, but essential key. It’s the one-time-task that unlocks your ability to bill for MTM, POCT, vaccines, and all the other high-value services we discuss in our Beyond the Counter: A Pharmacist’s Guide to Launching New Revenue Streams.

You are a provider. This is how you finally get paid like one.