Frequently Asked Questions

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What are the differences between Payer/Provider Enrollment, Contracting and Credentialing?

Enrollment is the process of applying to health insurance plans for inclusion into provider networks for reimbursement of products/services rendered to patients.  


Contracting is the process of negotiating and establishing a products/services agreement between a healthcare provider and an insurance payer, which details provisions for services provided and covered, claims submission, reimbursement rates, payment terms, agreement terms & termination, providing notices to parties, etc.


Credentialing is the process of obtaining and verifying a healthcare provider's identity, qualifications and competencies to provide care for patients within a healthcare organization.


What is an NPI number, and how do we apply for one?

An NPI is a National Provider Identifier issued by the federal government to health care providers. It is intended to improve the efficiency of the health care system and help to reduce fraud and abuse.  Healthcare providers can apply for NPIs by visiting https://nppes.cms.hhs.gov/.


My organization has an NPI number. Does that mean we can bill insurance companies?

No.  While providers can bill using an NPI number, just because your provider organization has an NPI number does not mean it can bill insurance payers.  Providers need to be enrolled, contracted and credentialed with insurance payers in order to bill for services rendered.


What is the difference between Medicare and Medicaid?

Medicare is the federally funded insurance program that provides health coverage to individuals 65+, or under 65 and have a disability, no matter their income. 


Medicaid is a state and federal program that provides health coverage if you have a very low income. It is run by state and local governments within federal guidelines.  Each state administers its own Medicaid program.  In California, Medicaid is called Medi-Cal. 


They can work together to provide health coverage and lower costs to beneficiaries.  


What is Managed Care?

Managed Care is a system of healthcare in which patients agree to visit only certain doctors and hospitals, and in which the cost of treatment is monitored by a managing company.

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We are a healthcare start-up and want to bill for our products/services. What should we do first?

The answer to this depends on what your organization currently has in place and which payers and plans the provider wants to bill.  Generally speaking, a service location is needed with working phone, fax and company email address.  Applicable licensure, registrations, proof of liability insurance, accreditation is needed if required for your provider type.  We have a list of possible requirements, please contact us for help!


How can I tell if my provider type requires an Enrollment Application fee?

There is a provider enrollment application fee matrix located on the CMS.gov website, under Medicare, that shows what provider types and application types require the provider to pay the enrollment fee.  The enrollment fee is set by CMS annually.  For Coverage Year (CY) 2019, the enrollment fee is $586.


What is a Medicare MAC?

MAC stands for Medicare Administrative Contractor. MACs are multi-state, regional private health care insurers that are contracted by CMS to enroll and administer/process Medicare Part A, Part B and DMEPOS claims and payments for Fee-For-Service (FFS) beneficiaries. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare FFS program and the health care providers enrolled in the program.  For information on who your provider/organization’s MAC is, please visit CMS.gov/Medicare.


What is the difference between the IRS CP575 and the IRS Letter 147C?

The CP575 is issued by the IRS at the time the Tax ID number is assigned. The Letter 147C is issued when the entity requests a verification of its Tax ID number.


What is the best way to verify that my provider has been added to a payer once the effective date is

It's always best to inquire with both contracting and network management departments. 


How can I find out which Managed Medicaid plans are available to enroll in my state?

There is typically a section on Managed Care on each state’s website that has a list and contact information for each plan.  Not sure where to start?  Contact us for help!

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What is typically asked for in a Letter of Interest?

Payers asking for a Letter of Interest (LOI) as part of their application process usually require the provider’s practice information including name, legal business/entity name (LBN), Tax ID, NPI, area of specialty, geographic location/specific patient population served, and contact information. If applying to a narrow network, it might also be helpful to include “selling” features and benefits to help the provider become in network.  Need ideas for your provider's Letter of Interest?  Reach out to us for help!


What is required to enroll a DMEPOS provider in Medicare?

Please refer to the 30 DMEPOS Supplier Standards that can be found on the National Supplier Clearinghouse (NSC) website at: palmettogba.com/NSC.


I have a Family Nurse Practitioner (FNP) client who I'm trying to get enrolled & credentialed with many insurance companies. Will s/he need to have a collaborating doctor?

Yes, a supervising physician is typically required.


How long does the Enrollment process take?

Enrollment processing times vary greatly by payer, but in our experience, it is not uncommon for payers to take 60-180 days from start to finish.


Do most payers require physical/hard copies of licenses etc, or do they accept proof of Primary Source Verification (PSV)?

Depending on the payer, some require physical copies of licenses, some will accept electronic copies, and some will accept verification printouts from websites, etc.


What are the most common reasons for network denials from payers?

The most common reasons for network denials from payers are: network is at capacity/over saturation for a particular provider type; failure to meet a certain criteria required for participation; moratoriums on adding new providers.  Have an Enrollment denial from a payer?  Check out our article on strategies for overcoming network denials.  Still need help?  Contact us for help!

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I'd like to start my own Payer Enrollment business and don't know where to start. Can you guide me?

Absolutely!  There is definitely enough business to go around and there is definitely a need for Enrollment consultants for all provider types and specialties. Contact us to help find your niche and what it takes to get started!


I specialize in Billing but would like to learn about Enrollment. Can you help teach me the basics?

Yes!  It is a good idea for Billing specialists to have a fundamental knowledge of Payer Enrollment.  If you're in Billing or RCM, and could use help in explaining the Enrollment process, requirements, and/or common terms and acronyms, please reach out to us to set up some one-on-one training!


I have some questions about Payer Enrollment and am not sure who to ask. Can you help?

We will surely try!  If we can't answer your questions, we can refer you to someone who can.  Please send inquiries via our Contact Us page.


My organization needs online/newsletter content on Payer Enrollment topics. Can you help?

Yes!  We stay on top of the latest Payer Enrollment trends, information, hot topics  and challenges facing the Enrollment industry.  With almost 20 years of experience, we have plenty to talk about and have helped many organizations with interviews, articles, presentations and webinars. Check out our Blog/Media section, Enrollment Education page, and Testimonials page to see what we've done and how we can help you too!


How much do you charge for your services?

We customize our services to meet the specific needs of each client.  Please Contact Us for information on our pricing structure and to receive quote for your project.