Payer enrollment is an integral part of revenue cycle management and it includes the steps for a provider to join a specific insurance network. Payer enrollment includes two key processes of credentialing and contracting, which could vary based on the payer.
Credentialing is when a provider submits a participation request to the payer they would like to be in-network with. Once the application is submitted, the player performs a thorough credentials verification process to ensure that the provider meets the credentialing requirements. When the credentials verification i.e. primary source verification is complete, the credentialing file goes to the credentialing committee for approval. Once approved, the contracting process begins.
Contracting is when a provider has been approved by the credentialing committee and is extended a contract for participation in the network. The provider then reviews the contract received, including legal language, terms, reimbursement rates, and other responsibilities of participation. If the provider is satisfied with the contract, then they sign the agreement, and an effective date is received with a provider number. The provider can then begin billing that payer and receive in-network reimbursements for their claims.