Credentialing and Payer Enrollment

How it works

A health plan checks the provider’s license, education, board certification, malpractice coverage and history, usually drawing on the provider’s CAQH ProView profile, which must be re-attested every 120 days. Enrollment then links the provider to the plan, a contract and, for groups, the group’s tax ID and locations. Medicare enrollment is done through PECOS and must be revalidated every five years.

Why it matters

Claims for a provider who is not enrolled — or not linked to the right group or location — are denied, and many plans will not pay retroactively. Enrollment for a new provider should start well before their start date.

Example

A group adds a new physician and enrolls them with Medicare, but the reassignment of benefits to the group is not filed. Claims under the group deny until it is. See credentialing services.