Provider Credentialing And Payer Enrollment.
A provider who is not enrolled cannot be paid, however good the claim. We prepare payer applications, follow up and keep you updated on every status, so you can see where each application stands before patients are booked.
- Included with Full RCM
- Or ordered separately with Medical Billing
- Scope agreed before work begins
Fictional example. Payers set their own review times.
Practice ManagerSigns and approves
Credentialing, Contracting, Enrollment.
People use these words interchangeably. Payers do not, and confusing them is how providers end up seeing patients they cannot bill for.
Credentialing
The payer verifies the provider's qualifications: license, board certification, DEA, malpractice coverage, education and work history.
Contracting
The practice and payer agree participation terms and a fee schedule. Your practice reviews and signs contracts.
Enrollment
The provider is loaded in the payer's system, linked to your group, tax ID and locations, with an effective date. Only then do claims pay in network.
What Every Application Depends On.
Provider Identifiers
An individual NPI for each provider and an organizational NPI for the group, with matching names, addresses and taxonomy.
CAQH ProView Profile
Most commercial payers pull credentialing data from it. Profiles must be re-attested regularly, about every 120 days, or applications stall.
Medicare Enrollment
Individual enrollment plus reassignment of benefits to the group, so Medicare pays the practice.
State Medicaid And Plans
State enrollment first, then each Medicaid managed care plan, each with its own process.
Commercial Applications
Each payer's application and, for new groups, a contract. Some networks are closed to new providers.
Hospital Privileges
Included. We prepare and track privilege applications with each hospital, alongside payer enrollment.
Know The Effective Date Before You Book.
The effective date decides which claims can be paid. It is the single most important line on an approval.
Limited Look-Back
Medicare can allow billing for services up to 30 days before the application was filed, when the provider met all requirements. Earlier services cannot be billed.
Usually No Retro Pay
Most commercial plans pay in network only from the effective date. Services before it may be out of network or not payable at all.
Start Early
Payer reviews can take weeks to months. Starting applications well before a provider's first day gives their schedule the best chance.
What We Handle, And What We Confirm.
Credentialing does not end at approval. Profiles, licenses and enrollments expire or need updates when you add a location or change your tax ID. We agree in writing exactly which tasks are in your scope.
- Payer applications prepared and submitted
- Follow-up with payers until a decision
- Status updates as each application moves
- With Full RCM, coordination with billing
- CAQH profile upkeep and re-attestation
- Medicare and Medicaid revalidations
- Commercial recredentialing cycles
- Updates for new locations or tax IDs
Three Parties, Clear Roles.
Your PracticeSupplies accurate provider and business information, reviews contracts, and completes signatures the payer requires.
OneBill RCMPrepares applications, follows up and keeps you informed, within your agreed scope.
Reviews and decides. We cannot promise network acceptance, a reimbursement rate or an approval date.
Questions Practices Ask.
Is Credentialing Included With Medical Billing?
No. It is included with Full RCM and ordered separately with Medical Billing.
How Long Does Enrollment Take?
It depends on each payer. Reviews can take weeks to months, which is why we recommend starting before a provider's first day.
Can A New Provider See Patients Before Approval?
They can see patients, but claims may not be payable in network before the effective date. Medicare allows a limited look-back; most commercial plans do not.
Can You Guarantee A Payer Will Accept Our Provider?
No. Payers decide acceptance and timing. Some networks are closed to new providers.
Do We Need To Send Patient Information?
No. Credentialing uses provider and business information only.
Start Enrollment Before Day One.
Tell us how many providers need support, your locations and which payers you work with. Please leave provider records and patient information out of the form.
- Included with Full RCM, or ordered separately with Medical Billing
- Scope and price agreed before work starts
- Status updates as each application moves