While bringing on new physicians or other clinicians is an important part of building your medical practice, enrolling them with commercial and government payers can be time consuming…and costly. The tedious process leaves plenty of room for error and delay, both of which can mean missed opportunity for payment. As you work through enrolling providers, here are a few tips to ensure a timely and successful process.
Enrolling a provider can take up to three months, depending on the payer. While most will consider the date the application is received as the effective date–Medicare even allows providers to bill for dates of service up to 30 days before the complete application is received–filing limits often still apply. Indiana Medicaid, for instance, says, “Providers can bill for covered services rendered to IHCP members starting on their enrollment effective date, subject to the claim filing limit of 180 days from the date of service (or date of discharge, for inpatient claims).”
Lots of information is needed to enroll (also known as “to be credentialed”) with commercial and government payers, including:
- Current licensing information to practice in each state where services are provided
- Education/Training to support requested specialty(ies)
- Current Hospital Privilege information
- Current DEA or CDS certificate in each state where services are provided
- Work history
- Current Professional Liability Insurance
As well, providers may be asked to provide additional documentation to be attached to the application, including:
- Internal Revenue Service (IRS) CP-575 form, which grants your employer identification number (EIN).
- Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588)
- Licenses, certifications and registrations required by your state, city and/or county boards (e.g., State of Florida Professional License, CRNA Recertification, Health Care Clinic Licenses, Radiation Control License, FDA Mammography Certification, CLIA, Diabetes Education Certificate)
- Any Adverse legal action documents
Gathering the information ahead of time will streamline the application process, especially if you are a staff member or billing company working on the application for the physician or clinician.
Follow Directions Carefully
Even though many payers use the standardized Council for Affordable Quality Healthcare (CAQH) ProView application for credentialing, most will also have additional forms or requirements to complete as well. Read through the instructions carefully, looking particularly for the following:
- The name reflected in your NPI and on the enrollment applications matches your legal business name with the IRS
- All signatures are in place by the correct person who needs to sign (practitioner, practice owner, authorized/delegated official, person completing application).
- All attachments are added before the application is submitted.
Often, the application is not considered complete–and the effective date is thus delayed–until all information, signatures, and attachments have been received.
Finally, be sure to track all enrollment applications you have submitted so you can respond promptly if any additional information is needed. Not only do those requests often have deadlines, any delays could mean a later effective date for the enrollment.
For more information about enrolling, or credentialing, providers with commercial and government payers, check out the following resources:
- Top Tips for Medicare Provider Enrollment from the CIPROMS blog
- Steps to Successful Submission of a Provider Enrollment Application from WPS-GHA Medicare Administrative Contractor
- Avoid Delays with Medicare Enrollment – Help Us Process Your Application from WPS-GHA’s YouTube Channel
- MLN Educational Tool: Medicare Provider Enrollment
- Medicare Effective Dates Presentation from the 2019 National Provider Enrollment Conference
- Indiana Health Coverage Programs Provider Enrollment Provider Reference Module
- CAQH Proview Quick Reference Guide
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