Enrollment with Commercial Health Plans
Provider enrollment/payor enrollment consists of 2 steps for commercial payers: credentialing and contracting.
To submit a request to participate in the plan, the provider must follow the plan’s application process. The payor may use CAQH, a standardized state application, or its own unique application.
After receiving a provider’s application, the payor verifies the provider’s credentials, through Primary Source Verification (from the original source), according to its credentialing requirements. Then, the plan’s Credentialing Committee approves or rejects the applicant.
The credentialing step may take up to 90 days.
After approval from the Credentialing Committee, the payor offers the provider a contract for participation. The provider reviews the reimbursement rates, provider responsibilities, and other details outlined in the contract’s language. If applicable, the provider may negotiate rates.
Once the provider signs and returns the contract to the payor, the provider receives a provider number and effective date and can start billing the plan for in-network reimbursement on claims.
The contracting step may take 30-45 days.
Keep in mind that these steps must be performed for EACH insurance plan in which the provider wishes to participate.