Prerequisites
- The PC formed, with EIN, CP 575, and W-9
- Type 2 NPI with correct taxonomy
- Each clinician’s Type 1 NPI and an attested CAQH profile
- Malpractice coverage meeting payer minimums
- The PC’s bank account for EFT
Steps
1
Prioritize by market share, not alphabetically
Find out which payers actually cover your patients. In most markets one or two plans dominate, and the local Blue is frequently the largest. See The US payer landscape.
2
Submit a letter of interest or request for participation
Most payers have an online form. You’ll provide the PC’s legal name, EIN, Type 2 NPI, taxonomy, service address, specialty, and clinician roster.
3
Get the panel status answer early
“The panel is closed for your specialty in your area” is a real answer with no immediate appeal. Ask this before investing months.If closed, ask:
- What would change the answer? (New location? Underserved area? Extended hours? A subspecialty?)
- Is there a waitlist, and what is its timeframe?
- Are single-case agreements available for individual patients in the meantime?
4
Request and read the fee schedule before signing
Ask for the allowed amounts for your 20 highest-volume codes, and confirm whether the schedule references current-year Medicare or a frozen prior year. See Underpayments, fee schedules, and payer contracts.
5
Read the contract terms that cost money later
6
Execute, with the PC as the contracting party
Signed by the PC’s authorized officer. The MSO provides contracting support; the PC signs. See What an MSO can and can’t do.
7
Submit credentialing for each clinician
Most payers pull from CAQH. Confirm the payer is authorized in each clinician’s profile and that attestation is current.Expect 90–180 days. Committees often meet monthly, so missing a cycle costs a month.
8
Request retro-effective dates in writing, at application time
Ask explicitly for an effective date backdated to the application date or the practice start date. Some payers grant it routinely; many do not. You will never get one you didn’t ask for, and asking after the fact is much weaker.
9
Complete EDI, ERA, and EFT enrollment
Separate from contracting and credentialing. See Set up EDI, ERA, and EFT.
10
Follow up every two weeks, and log it
Applications rarely get denied — they go quiet. Call, note who you spoke to, when, and what they said. That log is what gets a retro-effective date approved later.
Single-case agreements
A one-off agreement to cover a specific patient’s care at a negotiated rate, used when you’re out of network but the patient needs you. Useful when: the panel is closed; a patient has a continuity-of-care need; you provide a service unavailable in-network; or an existing patient’s plan changed. Get it in writing before delivering the care, with the rate, the authorized services, and the timeframe specified. A verbal agreement to “work something out” is not a single-case agreement.Delegated credentialing
Once you have scale, typically dozens of clinicians, some payers will delegate credentialing to you under a delegation agreement, subject to their audit. It shortens onboarding dramatically. Worth asking about once you’re large enough. It requires an auditable, documented credentialing process, which is another reason to build one properly from the start.Verify it worked
- Fee schedule reviewed before signing
- Timely filing limit and appeal deadline recorded in the tracking grid
- Network access and all-products clauses understood
- Contract executed by the PC’s officer; effective date recorded
- Each clinician credentialed and linked; provider effective dates recorded
- Retro-effective dates requested in writing
- EDI, ERA, and EFT complete, with EFT to the PC’s account
- Follow-up log maintained