Questions You’ll Ask Before You Start Provider Enrollment

How do I know which insurances I need to enroll with?
· We suggest the major payors in your region as a starting point
· What patients have you turned away because you are out of network, or unsure of your network status with their plan?
· Who is your patient base? If geriatrics, Medicare would be a good option. Pediatrics? Medicaid.


How long does the payor enrollment process take to finalize?
· Each insurance company processes applications on their own timeline. Typically, 90-120 business days.


What information and documents are required to enroll with insurance networks?
· Documentation can vary due to specialty, practice type, geographical location, etc.
· Most common information required is Demographics, NPI, Licensure, Work History, Education History, and Malpractice Coverage


What is CAQH, and is it required?
· CAQH ProView is an online provider data-collection tool utilized by many health plans in lieu of a traditional paper credentialing application.
· It is now required by most commercial health plans.
· More information on CAQH ProView can be found on their website


What happens if I don’t want to accept the payor’s offered reimbursement rates?
· It’s an offer, until you sign. Negotiate!
· Still not meeting your needs? Time to choose whether to sign or not. Is the volume worth the low rate? Potential to re-negotiate in a reasonable timeframe? The final decision is always yours.


When can we start treating members?
· Once the payor has credentialed, contracted, and assigned an effective date.
· If you choose to see members prior to the effective date, the claims will process as out of network. Check eligibility and benefits prior to the appointment to ensure the patient has out of network benefits.


We are in network, but claims are denying; why?
· This is potentially a load issue on the payor end. At times, the credentialing/contracting departments will reflect in network, but the load file has not completed. This will cause false denials. It is important to ensure your contract is fully loaded with the payor prior to submitting claims, unless close to timely filing.