top of page

Here is How Payor Enrollment Impacts Reimbursement

Updated: Sep 29, 2023

Enrollment impacts so much downstream. New Business, Recruiting, Contracting, RCM, all teams really should know the basics of Enrollment timelines. First, let's start with some clarifying terminology. Credentialing, Enrollment, MSOs, Providers, Payors, they all overlap in this space if the terms are not clearly stated. The descriptions below are my own, so they may not fit every company, or healthcare business.

  • Facility Credentialing - The Provider Credentialing at the facility is the process where the Credentialing Team links a provider to work at a specific facility or set of facilities per their contract.

  • Payor Enrollment - The Provider Enrollment at the payor is the process where the Enrollment Team works in partnership with the RCM vendor (or a contracted vendor) to link a provider and/or new facility location to a specific payor.

In most cases, the RCM vendor partner (or in-house back-end RCM teams) only work with the payor side, so they use the term Credentialing and Enrollment in combination. Now, I get it, the Enrollment team is technically also submitting credentials to the payors. But this is just to confusing. These are two separate and distinct processes, so I say, “Facility Credentialing” and “Payor Enrollment” to add clarity to conversations. Today we are talking about Payor Enrollment.

General Overview of Payor Enrollment

If you have never worked with payor enrollment then you may not have a baseline for the various timelines, and dependencies. Also, it should be noted that each state is a little different, and so is each payor. Since I physically reside in the state of Texas, I know I have rules here that are different than other states. There are also several types of enrollment submissions:

  • New group (billing entity/TIN) application

  • New provider add application

  • New location/site add application

  • Re-validations/re-enrollments

To break this down, we are going to start with a brand new Tax ID (TIN). The new group is starting at their service location, 90 days from today. They are in the state of Texas. They have around 60 providers (mix of physician and APP-level providers). Since it is a new group with new providers, we will be unlinked and out-of-network (OON) with all payors at our go-live date. To prepare for successful claim submission and reimbursement, we need to follow a standard strategy 90 days out from go-live. This starts, and always starts with Medicare.

  • Traditional Medicare (MCR) - This one payor is both the baseline and the timeline for all other payors. You cannot submit the Medicare application for the group until you are 60-days out from the go-live. You have to submit at least one individual provider application with the group application. The reason for the 60 days is if you submit earlier, you open yourself up for a timeline risk for the potential site visit audits. Yep, Medicare actually checks to make sure you are servicing the location for the time period you say you are. If they do a site visit, and you are not servicing those days, they will deny your application.

Some additional Medicare notes: The group and provider effective dates should always retro back to the start date if the provider was servicing/scheduled when the group started (i.e. the go-live date). It is important to have everything prepped before 60 days out (we can talk apps and timeline impacts at a later time), and that the group app is submitted as close to that 60 days out date as possible. Finally, once that first application for the group with at least one provider is submitted, you cannot touch it until it is finished. In our example of 60 providers, we may only have 20-30 of them ready at 60 days out from go-live. So we submit what we have and then wait. Medicare can take up to 120 days to process an application (thank goodness they are usually faster). So, worst case scenario you submit 20 providers with your app, then Medicare takes the full 120 days, and then you can submit the remaining 40 provider's individual apps. Yeah, I think you are catching onto that timeline now.... 60 days out, up to 60 days more....all that claim inventory for the group and/or individual providers unlinked (not enrolled) is sitting on hold. We will not get reimbursement until these steps are done, so please start as early as you can.

  • State Medicaid (MCD) - Since the example we are following is in Texas, we will need to make a distinction here. Texas Medicaid (TMHP) has a timeline dependency on traditional Medicare. This is not true for every state. In Texas, TMHP requires Medicare group and individual provider approval before you can submit the group and individual applications for Medicaid. Wait a not only is a portion of the Medicare inventory holding for app approvals, but now all of Texas Medicaid inventory is also holding? Yep, you got it. Other states can submit their Medicaid apps the same time as their Medicare apps, which saves a lot of claim processing and reimbursement delays.

  • Blue Cross Blue Shield (BCBS) - Even if you are OON at go-live, you still have to link to BCBS. Basically they have an enrollment process for both contracted and uncontracted groups. So it is best to start this early in your pre-go-live process to prep all the applications. Note: We cannot process BCBS until we get a Medicare number, group and individual.

I am going to pause here to add this statement that I have eluded to earlier. Once there is a new group app in process, or a location add to that group app, you cannot touch that application to add more things until it is done processing. If you are a practice with many locations coming on at different times, weeks or months apart, you really need to work with your Enrollment Team on the application strategy to ensure you are reducing claim inventory on hold as much as possible.

Two more to go....

  • Managed Medicare - You cannot submit to any of the Managed Medicare plans until the Traditional Medicare application has been approved, and that goes the same for each individual provider.

  • Managed Medicaid - You cannot submit to any of the Managed Medicaid plans until the state application has been approved, and that goes the same for each individual provider.

Oh look, more inventory on hold. The Enrollment Team is having to really watch the group and individual provider inventory. They make sure the moment the application is complete, and numbers provided, that they drop the claims for the associated provider/payor combination.

We cannot forget about claim Timely Filing limits by payor. This is where I would highly recommend you have an on-hold or held inventory report (billed and unbilled). If you are (1) holding inventory for enrollment, or (2) you have NPI/TIN/Provider not linked Rejections, or (3) if you had to bill inventory and received a denial. Some of these payors downstream from Medicare and Medicaid have shorter timely filing timelines. Factor these kind of flags/alerts into your inventory monitoring.

In a world where you factor in the longer timelines for payor processing of enrollment apps, I would say by around 150-180 days out from your go-live date for a new group, you should be in a steady state for inventory throughput. Meaning, the only inventory you should still be holding/monitoring is for one-off new providers adding to the group at a later date.

There is a lot going on in the Enrollment space, so I hope this encouraged you to reach out to your teams and get a better idea on where you have potential impacts downstream with reimbursement.

This is an example of how enrollment for a new group in the state of Texas may look.
Image 1: Enrollment Timeline Example (Texas)

Recent Posts

See All


Post: Blog2_Post
bottom of page