"But I am already enrolled with the payors..."

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Enrollment professionals frequently hear providers voice this common misconception. Providers often assume that once they are credentialed, they have completed the enrollment process and no more needs to be done. They sent in a multitude of signature pages, document copies, log-ins, and a large quantity of personal information to their enrollment specialist to complete enrollment. They patiently waited 90 to 180 days through the credentialing process, during which all information was verified, documented, and presented to a credentialing committee for final approval to the network as a participating provider. But wait, it’s not over yet.

Even though a provider successfully passes through the initial credentialing process and becomes a network provider, he or she may still find the services of an enrollment specialist to be helpful. Provider enrollment specialists work to maintain essential data between credentialing cycles. They submit updated licenses and malpractice insurance documents to plans that require it. They update demographic information with health plans when there has been a change in the information originally submitted. Adding locations, updating the payment or correspondence addresses, changing phone/fax numbers, and adding missing information are examples of some of the necessary demographic updates these professionals provide. Without adding every place of service location accurately to the provider file, the provider will likely have claims issues later on.

Provider enrollment specialists also research and resolve numerous issues that have caused claims to be denied. One issue frequently encountered can occur when a claim is dropped before credentialing is complete. In this case, the claims must be held until a notification has been sent confirming participation with the health plan; this is referred to as a “credentialing hold” in the billing department. If the provider is listed as effective with the plan and claims are denied, more research on the part of the specialist is needed. It is the responsibility of the enrollment specialist to explore what data needs to be corrected to resolve the issue.

Frequently, providers find that changing from one tax ID number (TIN/EIN) to another is a more complex endeavor than they expected. When a provider who initially joins a group practice decides to leave his or her contracted group to create a separate/new entity, it can require a new contract. The provider should be aware that the new TIN prompts a new effective date with the health plan since the plan typically uses the date the contract was executed. During this process, the guidance and services of a payor enrollment specialist can help smooth the way.

The credentialing process can be overwhelming to providers who are starting their own practice, changing employment, or relocating to another state where the health plans and rules are different. Providers increasingly find that the complex administrative work of the enrollment process is best left in the hands of an experienced provider enrollment specialist. By working with a specialist, a provider can streamline the process, getting the network participation effective date as soon as possible. In the end, the most important reason to delegate the process to professionals is to become enrolled as early as possible.

To learn more about the payor enrollment process and how outsourcing enrollment services can benefit your organization, download the white paper, Navigating the Payor Enrollment Process.Payor Enrollment from symplr

We offer complete client support to help you navigate the complexity of provider enrollment, saving you time and money. Learn more about Payor Enrollment Services at www.symplr.com/products/payor-enrollment-services or schedule a demo at [email protected].


Amanda Vaughn

About the Author
Amanda Vaughn

At symplr, Amanda is a Payor Enrollment Specialist with extensive knowledge in provider enrollment and credentialing. Her understanding of credentialing processes and requirements greatly enhances her ability to streamline the enrollment process, ensuring that providers are enrolled with health plans correctly and efficiently. Her previous experience includes hospitalist enrollment and credentialing, workers compensation provider credentialing, group enrollment, and individual/private practice enrollment. Working in close conjunction with providers and health plans provides her the ability to monitor changes in enrollment criteria, adjusting the enrollment process accordingly. Amanda has over 8 years’ experience in provider enrollment and credentialing.

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