For most major healthcare providers, the payor enrollment process can be a nightmare of forms, forms, and more forms – not to mention jumping through a few hoops. Inevitably, you just want to quickly get a practitioner enrolled into a payor program and start receiving payments for their services. Organization, technology and paying attention to details will make the application process go more smoothly, saving you time and effort.

Step #1:  Create a timely and organized payor enrollment process.

Payor enrollment can be complicated. Forms, timelines, and requirements will vary by institution and state. Having  an organized system to submit applications and get new providers working will make the process go smoothly, so consider these steps:

  • Start processing Individual payor enrollment as soon as you hire a new provider. The enrollment process can be lengthy, so begin as early as possible to avoid unnecessary delays. The faster you process your new provider applications, the faster they'll be approved.
  • Create a checklist outlining each payor’s required information. A centralized folder or links to payors’ forms and required information will help practitioners know exactly what information is required for a timely submission and approval, and include deadlines for completing enrollment.
  • Use a digital solution to ensure all credentials and privileges are packaged. Using credentialing solutions (like those offered by symplr) can help you streamline your payor enrollment and recertification and create a secure, scalable archive to store and manage important information. Easy access to this data will help streamline the payor enrollment application process.

 

Step #2: Select Health Insurance Plans and Networks

This process of applying to health insurance plans and various networks is what payor enrollment is all about. You’ll determine which plans you will be included in for provider billing and payment for services rendered. After they are credentialed and granted privileges, each practitioner must be enrolled. Here are the three main enrollment types:

  • Federal and State Programs (Medicare and Medicaid)
  • Private and Commercial Programs (BCBS, Aetna, UHC)
  • Worker’s Compensation (Commercial, US DOL)

Depending on your medical staff’s makeup and your organization’s partnerships, you may need to enroll practitioners into a compilation of several payor programs. The majority of the programs available are local and will likely be accessible through system directories like the Atlantic Information System Director of U.S. Health Plans (AIS). By accessing directories like AIS, your organization will gain an extensive network of health insurance companies operating in the United States.

 

Step #3: Address special enrollment requirements

In addition to the basic forms you’ve included in your enrollment process, there may be additional requirements to address unique situations.  For instance, there may be special licenses required by your state, preferred submission methods, or backdating restrictions.

Special requirements, including state laws, may exist for out-of-state providers. Areas to be addressed include:

  • Out-of-state license verification
  • Crossing over claims
  • Enrollment in only medicare programs (where state law restricts out-of-state enrollment)
  • Bonds or special agreements

If left unchecked, these issues could result in application delays or even non-payment from the patient’s primary insurance provider, so ensuring compliance for out-of-state providers is vital.

Step #4: Submit applications and follow up

Much of the information gathered in credentialing is then used in the payor enrollment application, helping you to avoid duplicate work. The applications for payor enrollment will ask for information similar to the credentialing process:

  • Identification
  • Education and training
  • Licensure
  • Certifications and affiliations
  • References and work history

Once the applications are completed and submitted, the process is handled by the payor group. The key to accelerating this process is to maintain clear communication until a determination is made. Following up on an application’s progress will clarify any questions and speed up the application process.

Not all groups send official letters and may have delays in their authorization, which can leave your practitioner in limbo. By being proactive, you can take immediate action If the application is denied and take corrective action.

Ready to simplify your payor enrollment process?

Clearly, taking a proactive approach to your payor enrollment process will lead to quicker revenue generation. It is true that much of the process overlaps with credentialing. However, by understanding the various nuances that can complicate credentialing, you can truly streamline the process.


Maintaining an efficient provider enrollment program is critical to protecting and growing your revenue. Payor Enrollment Services by symplr can help you cut through the noise to get your providers enrolled quickly – all in-house.  

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