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.
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/
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.
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.
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.
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!
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.
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.
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.
It's always best to inquire with both contracting and network management departments.
There is typically a section on Managed Care on each state’s website that has a list and contact information for each plan.
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!
Please refer to the 30 DMEPOS Supplier Standards that can be found on the National Supplier Clearinghouse (NSC) website at: palmettogba.com/NSC.
Yes, a supervising physician is typically required.
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.
Depending on the payer, some require physical copies of licenses, some will accept electronic copies, and some will accept verification printouts from websites, etc.
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!