Payer Enrollment Services

A provider can be licensed, board certified and fully credentialed and still not get paid. Payment needs one more step: the payer has to enroll the provider, link them to the group that bills, and load them in its system with an effective date. Until that happens, claims are denied, however good the care was.

Our payer enrollment services handle that last step for new providers, new groups and practices adding payers. Payer enrollment is one part of our credentialing services for providers, run the same way for every specialty: the application filed complete, the payer chased every week, and the effective date confirmed in writing.

Credentialing, contracting and enrollment are not the same

Most "we are credentialed but still denied" problems are the third row. We confirm all three before a provider's first claim goes out.

By payer type

Medicare

Enrollment runs through PECOS. A new provider files an individual enrollment and a reassignment of benefits to the group, and a new group files its own enrollment first. Medicare can usually backdate the effective date up to 30 days before the application was filed, which is one more reason to file early. See our guide to Medicare provider credentialing.

Medicaid

Each state runs its own enrollment, and many states then require a separate enrollment with each Medicaid managed care plan. Being enrolled with the state does not mean the plans will pay. See our Medicaid credentialing guide.

Commercial plans

Most pull credentials from CAQH, run them through a credentialing committee, and then either add the provider to an existing group contract or offer a new one. Some networks are delegated to another organization, so the application has to go to whoever actually owns the network. See our guides for Aetna, BCBS, Cigna and UnitedHealthcare.

What we do

• Build or clean up the CAQH profile and keep it attested. See CAQH credentialing.
• Pick the right application for each payer: new group, new provider joining a group, or a provider added to an existing contract.
• File complete applications, with every document the payer asks for.
• Follow up every week by phone and portal until there is a decision.
• Confirm the effective date and the group link in writing before claims go out.
• Track revalidation and re-credentialing dates so enrollment does not lapse later.

Physicians, and every other clinician

Practices enrolling physicians usually also have nurse practitioners, physician assistants or therapists to enroll. We handle physicians and every other clinician type the same way. See the pages for nurse practitioners and dentists, our credentialing services for therapists, and all our doctor credentialing services.