What Is Provider Enrollment?

Health Plan Provider Enrollment

Provider Enrollment (or Payor Enrollment) refers to the process of applying to health insurance networks for inclusion in their provider panels.  For Commercial Insurance networks, this process involves two steps, 1) Credentialing and 2) Contracting.  The first step is for the provider to submit a participation request to the health plan using their application process.  Health plan application processes vary from completion of a unique credentialing application, use of CAQH, or acceptance of a state standardized credentialing application.  When the health plan receives a provider enrollment application, they perform a thorough credentials verification of the provider to ensure he/she meets their credentialing requirements.  When all credentials verification (Primary Source Verification) is complete, their credentialing file goes to the Credentialing Committee for approval.  Expect networks to take up to 90 days to complete this process.  Once approved by the Credentialing Committee, the second phase of the process begins; Contracting.

The Contracting phase of enrollment is when the provider has been approved by Credentialing and is extended a contract for participation.  Most commercial insurance networks have staff dedicated to the contracting process and is separate from the credentialing step.  In the contracting phase of the Provider Enrollment process, you review the language of the contract, reimbursement rates, and all the details and responsibilities of participation, then sign your agreement.  This is the phase where you begin negotiation of rates if the standard reimbursement rates don’t meet your expectations.  Once your agreement is signed and returned to the network, you are given an effective date and provider number so that you can begin billing the plan and receiving “In-Network” reimbursement for your claims.  Expect networks to take 30 – 45 days for this process (after credentialing is complete).

Provider Enrollment in Medicare, Medicaid, Tricare, and other government health programs is a bit different.  These programs have standard forms that must be filled out and sent to the appropriate intermediary that handles all the administrative functions for the program in your jurisdiction.  Medicare reviews your application against strict enrollment standards.  You may find extensive enrollment information on the CMS website regarding the Medicare Provider Enrollment process.  Some key items to remember when applying for Medicare:

  1. You must have a primary place of service in operation (or in final preparation)
  2. You’ll need banking information to setup EFT payment for your Medicare reimbursement
  3. You must provide personal details of every individual having an ownership stake in your practice
  4. Supporting documents vary with the type of provider enrolling
  5. Citizenship documents are required for providers born outside the U.S.
  6. ECFMG certificate is required for providers eduction outside the U.S.
  7. Sign your application forms correctly in every signature location

The Medicare enrollment process is very detailed.  It is always wise to have someone experienced in Medicare enrollment review your application prior to submitting.

Regardless of who is handling your provider enrollment applications, the primary thing to consider is DO NOT WAIT.  The process can be lengthy and you won’t receive “In-Network” reimbursements until your contract is in effect.  Medicare, is a bit different in that you can bill 30 days prior to the date they receive your application (your “Effective Date”).  So if Medicare takes 60 days to complete your application, you can back bill to your effective date; but commercial carriers don’t allow that type of back billing.