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 1) Credentialing and 2) Contracting.  During the first step, the health plan does a primary source verification of the providers credentials (license, education, training, etc) and once complete the providers credentialing file is presented to the plans credentialing committee for approval.  Expect a 90-120 day turnaround time for health plans to complete credentialing.

After credentialing is completed and approved, the Contracting phase begins.  Most commercial insurance networks have staff dedicated to the contracting process and is separate from the credentialing step.  In the contracting phase, you are provided with a network agreement for your review and execution.  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 government health plans such as Medicare, Medicaid, and Tricareis 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:

  • You must have a primary place of service in operation (or in final preparation)
  • You’ll need banking information to setup EFT payment for your Medicare reimbursement
  • You must provide personal details (name, DOB, SSN, place of birth, etc) of every individual having an ownership stake in your practice or a management position in your practice (Your ownership records must match your state corporation filings)
  • Supporting documents vary with the type of provider enrolling
  • Citizenship documents are required for providers born outside the U.S.
  • ECFMG certificate is required for providers education outside the U.S.
  • 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.  Expect a Medicare application to be completed in 60-90 days if there are no unusual issues.  Medicare will provide you with an effective date of 30 days prior to receiving your application, OR the first date you saw a Medicare patient as provided on your application, and you can bill Medicare for all dates of service from your effective date forward.  So, even if Medicare takes 3 months to process your application you can retroactively bill Medicare from your effective date and receive reimbursement.

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 from commercial payors until your contract is in effect and you can’t bill Medicare until you receive your approval letter and effective date.