A Step-by-Step Guide to Getting In-Network with Commercial, Medicare & Medicaid Payers
Becoming an in-network provider with commercial insurance plans, Medicare, and Medicaid is a critical step for any healthcare professional or organization aiming to serve a broader patient base and ensure consistent reimbursement. However, the path to becoming in-network can be time-consuming and complex, especially if you're navigating it for the first time.
This step-by-step guide will break down the process into manageable stages for commercial, Medicare, and Medicaid payers, so you can move forward with confidence and efficiency.
Why Being In-Network Matters
Before we dive into the steps, it’s important to understand why getting in-network matters:
Access to more patients: Many patients prefer (or are required) to see in-network providers due to lower out-of-pocket costs.
Faster and more reliable reimbursement: In-network providers benefit from pre-negotiated rates and streamlined claims processes.
Credibility and trust: Being listed on payer directories enhances your legitimacy and visibility.
Now, let’s get into the process.
Step 1: Organize Your Documentation
Whether you're applying to commercial insurers, Medicare, or Medicaid, preparation is key. Gather all necessary documents upfront, including:
National Provider Identifier (NPI)
State medical license(s)
DEA registration (if applicable)
Malpractice insurance certificate
Board certification (if required)
Curriculum vitae (CV)
CAQH profile (for commercial payers)
Tax ID (EIN or SSN)
Practice location details (including W-9)
Tip: Keep a digital folder with these documents readily available—you’ll use them repeatedly.
Step 2: Create or Update Your CAQH Profile (Commercial Payers Only)
Most commercial insurers use the Council for Affordable Quality Healthcare (CAQH) for credentialing. If you haven’t already:
Create a profile at https://proview.caqh.org
Fill in your professional and practice details
Upload required documents
Authorize individual payers to access your data
Keeping this profile current is essential, as insurers will not proceed without it.
Step 3: Apply for Credentialing
For Commercial Insurance Plans:
Identify which insurance panels you want to join (e.g., Aetna, Cigna, UnitedHealthcare).
Visit each payer’s provider portal or website to find their “Join Our Network” or “Provider Enrollment” section.
Submit an application expressing interest in joining the network.
Wait to be contacted to begin the credentialing process (or receive a rejection if the panel is closed).
Note: Payers may take 60–120 days to respond. Persistence and follow-up are crucial.
For Medicare:
Go to the PECOS system at https://pecos.cms.hhs.gov
Create a PECOS account or log in
Complete the Medicare Enrollment Application (Form CMS-855I) for individual providers, or CMS-855B for group practices
Upload your documents and submit
Once your application is reviewed and approved, you’ll receive a PTAN (Provider Transaction Access Number), making you eligible to bill Medicare.
Timeframe: Typically 45–90 days, depending on accuracy and completeness.
For Medicaid:
Enrollment varies by state, so you’ll need to:
Visit your state’s Medicaid provider enrollment portal
Submit an application along with required documentation
Undergo credentialing (may include fingerprinting or background checks)
Complete any required training (some states require compliance training modules)
State-specific example:
In Texas, use TMHP.com
In California, visit DHCS.CA.gov
Timeframe: Medicaid enrollment can take 60–120 days and varies widely by state.
Step 4: Undergo Credentialing & Verification
Whether you're applying to commercial, Medicare, or Medicaid payers, credentialing is a core part of the process. This involves the payer verifying:
Your education and training
Licenses and certifications
Work history
Malpractice history and sanctions
This process may include:
Peer references
Credentialing committee reviews
Site visits (for some Medicaid programs)
Tip: Always respond promptly to any requests for clarification or additional documents—delays here can cost you months.
Step 5: Sign the Participation Agreement
Once credentialing is complete, and the payer agrees to add you to the network, you'll receive a contract or participation agreement. This document outlines:
Reimbursement rates
Billing and documentation requirements
Provider obligations and limitations
Important: Review this carefully—preferably with a healthcare attorney—to ensure fair rates and clear expectations.
After signing, you’ll be officially listed as in-network with that payer.
Step 6: Confirm Listing and Start Billing
Once the agreement is finalized, double-check:
You’re listed correctly in the payer’s provider directory
Your NPI and TIN are linked correctly to your practice
Your staff knows the effective date of in-network status (you can’t bill as in-network until this date)
Now you can start submitting claims and getting reimbursed as an in-network provider.