Payor Enrollment: Understanding the CMS Guidelines for Hospitals and Health Plans

When it comes to processing enrollment applications, there are many requirements for hospitals and health plans, including Centers for Medicare and Medicaid (CMS) and state regulations, as well as requirements established by various healthcare accreditors. With so many rules and regulations in place, it can be difficult to navigate the payer enrollment process—let alone get applications approved in a rapid manner.

To be an efficient and effective payor enrollment specialist, it helps to understand the requirements for processing hospital medical staff and health plan enrollment applications.  With the right preparation, you can avoid delays and ensure your providers are granted privileges as quickly as possible.

The minimum requirements that must be met by providers to gain hospital or medical staff privileges include:

  • Documentation of clinical privileges – CMS requires documentation of a request for clinical privileges at a hospital. Each individual facility defines that criteria. For example, an internal medicine physician requesting privileges for colonoscopy may be required to prove he or she performed at least 50 procedures in the past two years as the primary operator before the provider is able to request privileges for that procedure. Be prepared to provide this information as part of the medical staff application.
  • Evidence of current licensure – In order to gain privileges at a hospital, providers must have current medical licenses. Verify a provider’s license is up-to-date by visiting your state medical or nursing board website. Simply type in the name and license number of the provider to validate the license. Making sure the provider’s license is valid from the get go will save you time in the long run.
  • Verification of professional education – It’s also important to verify all relevant training, including any recent fellowships or residency programs. Obtain proof of an approved training course related to a provider’s specialty by contacting the program director individually. When reaching out, include a copy of the clinical privilege request and ask the director to verify the provider’s competency in the course.
  • Proof of experience and competency– CMS requires providers to deliver proof of professional experience and competency in order to gain medical staff privileges. In some cases, you may be asked to provide a list of procedures performed by the provider. However, the hospital will contact the places where the provider is currently working or has worked in the recent past to get this information. In this case, it is best to have the provider reach out directly to these organizations , as they may have restrictions that prohibit releasing information to third parties without personal authorization from the provider.
  • Supporting references – To verify the competency of providers, CMS also requires supporting recommendations of competency. These recommendations are typically sought from peers and current or former medical staff leaders who have had oversight responsibility of the practitioner. Review the enrollment application to determine who is most appropriate to list as a reference for the provider. This person should be someone who is currently familiar with the provider and able to verify his or her competency at this point in time. Most importantly, it should not be a family member, partner, or spouse. Contacting these references ahead of time to make sure they are willing to provide a recommendation and to verify contact information can help speed up the enrollment process.

CMS also establishes a minimum set of requirements that must be met by providers to be credentialed with health plans. These include:

  • Current licensure – The provider’s license must be current at the time of the credentialing decision.
  • Relevant education and training – The health plan will obtain proof of professional schooling and/or completion of a residency or specialty training program, if applicable. Only the highest level of training needs to be verified. For example, if they verify completion of the residency, they don’t have to verify medical school or internship.
  • Board certification(s) – Provide documentation of any board certifications related to the provider’s clinical specialties. Board certification in each clinical specialty area for which the HC professional is credentialed will be verified. Verification of board certification is highest level provided that board itself verifes education and training. This means that, in some cases, the health plan may only need to verify board certification and this will meet CMS requirements for verification of all training.

While some hospitals and health plans choose to go above and beyond these requirements, CMS’s Interpretative Guidelines provide a good benchmark to guide you in completing and submitting your enrollment applications. With a clear grasp of these rules—and the right systems and tools in place—you will be better equipped to optimize your efforts as a payor enrollment specialist, which in turn will help generate more revenue for your providers. To learn more about expediting the payor enrollment process, listen to the symplr webcast, How to Avoid the Payor Enrollment Black Hole.

Greatly reduce your payor enrollment wait time and start generating revenue faster with Payor Enrollment Services by 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 or schedule a demo at

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