Before a physician or other clinician can bill an insurance company, whether private or government-run, for services furnished to patients, he or she must be enrolled in or be credentialed with that payer. Through this process, payers request a variety of information from clinicians and/or their employers on licensure, contact information, schooling, practice history and more. While once viewed primarily as a vehicle for payment, today’s enrollment or credentialing processes are viewed more as a fraud prevention vehicle, designed to prevent clinicians from billing fraudulently for services that may or may not have been furnished.

Each payer has its own process for enrolling or credentialing practitioners:

Medicare Provider Enrollment

The Medicare provider enrollment process has gone through numerous changes in the last several years, a number of which have allowed the Medicare program to make great strides in the processing of enrollment applications. Practitioners now have the option of filing their application via paper or electronically. The well-known CMS-855 forms can still be used. The new electronic system, referred to as Internet-based PECOS or just PECOS, can also be used for those interested in a more efficient enrollment process.

PECOS allows practitioners to submit all of the enrollment materials electronically. One of the newest features of PECOS is the electronic signature function. Rather than having to submit a signature page separately from the electronic application, the CCMS now allows practitioners to use an electronic signature to file the enrollment application. Additionally, copies of relevant supporting documentation can be scanned in and submitted electronically. This has improved the efficiency of the process tremendously.

As of 2006, Medicare practitioners can only retroactively bill for services furnished up to 60 days prior to the effective date of their Medicare enrollment. Cardiologists, nurse practitioners and physician assistants are encouraged to submit enrollment applications (or to have their employers submit enrollment applications on their behalf) as soon as possible to ensure the applications are processed by their start date.

Additionally, Medicare practitioners are required to revalidate their enrollment information every five years. Practitioners will be contacted by their Medicare contractor when it is time to revalidate their information. Responses must be submitted within 60 days. Medicare practitioners are also required to notify their Medicare contractor in the event of any changes to their enrollment information.

Medicare Provider Enrollment News

  • Specialty designation codes updated for electrophysiology (Dec. 2010)
  • New enrollment rules regarding practitioners who order or refer patients for services, including diagnostic tests (March 2013)
  • The Affordable Care Act and Medicare provider enrollment (March 2010)

Resources and Contractor Contact Information

Private Payer Provider Enrollment

For private payers, provider credentialing refers to the collection and verification of a provider's professional qualifications. The qualifications are then reviewed and verified to include any relevant medical training, licensure, certification and/or registration to practice in a health care field, and academic background.

Historically, medical providers wishing to participate in private payer provider networks must complete a credentialing process for each health insurer. The process would require providers to submit applications with supporting evidence and documentation to each payer separately. As a result, completing the credentialing process for numerous payers could be labor and time intensive.

Like Medicare, some health insurers, including large national payers such as UnitedHealth, CIGNA, Aetna, and many Blue Cross and Blue Shield plans, are beginning to standardize and reduce the burden of their credentialing programs by utilizing single online vendors, like the Coalition for Affordable Quality Healthcare (CAQH) Universal Credentialing's Datasource and Oregon and Washington's ProviderSource. These vendors allow providers to store their credentialing information and documentation for submission to various health plans and hospitals at zero or limited cost.

Since these vendors are health plan specific, providers are encouraged to check with the prospective insurers to determine the most appropriate vendor.