Difference Between Medical Credentialing and Payer Enrollment?

Most people are unsure of the difference between medical credentialing and payer or provider enrollment. Believe it or not some individuals in the healthcare industry do not know how they differ.

The truth is that both are a type of credentialing process: Medical credentialing generally refers to primary source credentialing, which is a type of a professional background check on doctors and other health care providers.

Payer enrollment (sometimes known as provider enrollment) is the process by which a medical provider gets entered onto insurance plans, networks, Medicare and Medicaid so the provider can be paid for services rendered to those patients. Both medical credentialing and payer enrollment credentialing are essential functions of the healthcare industry.

Payer Enrollment Basics

Most providers and individual practitioners choose to be enrolled with major health plans in order to be considered "in-network” providers. This is an important distinction because patients almost always prefer to be seen by in-network health care providers. Plan participants usually realize cost savings by using in-network providers. Cost is always a major motivator in American culture.

In order for a medical provider to be enrolled with a payer, a network, plan, Medicare or Medicaid they must meet specific criteria to be credentialed. At this point, an enrollment specialist can be extremely beneficial. Making errors or not knowing your way through the process can lead to denials, rejected applications and lost time. Utilizing a credentialing specialist such as Eddy will help to eliminate these issues.

It's important that all application information be complete. If anything is missing, Eddy will be notified and we will submit the correct information for you. The networks review proper licensing, any malpractice claims, provider specialty training and education. The application and approval process can take some time to complete - for example, Medicare and Medicaid typically take up to 120 days and commercial carriers like Aetna and Blue Cross typically take up to 90 days to complete. A specialist like Eddy can expedite this process and make it less time consuming and more efficient.

Our team will follow up on all applications until an effective date is assigned to the health care provider. This signals that the provider has been approved as in-network and claims can now be paid.

The team at Eddy are standing by. We are ready to help you with our simple, one and done, interface allowing you to enroll and credential with multiple payors with a simple form filled out once. Reach out today to learn more about our competitive and industry leading upfront pricing.

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