Getting in network: payer enrollment for a chiropractic practice.

Four layers, in order

“Getting credentialed” is shorthand for four separate things. Each one depends on the one before it, and a gap in any of them stops payment.

Identity: NPIs and taxonomy

Each chiropractor needs an individual (Type 1) National Provider Identifier. If the practice is a corporation or LLC, it needs its own organization (Type 2) NPI as well; a sole proprietor uses only the individual one. You apply online through NPPES, the national registry. The taxonomy code for a chiropractor is 111N00000X. An NPI identifies your provider; it does not credential or enroll you with any payer.

Keep the name, address and taxonomy in the national registry identical to what you put on payer applications and claims. A mismatch between the registry, the payer’s file and the claim is one of the quietest causes of rejected claims later.

The CAQH profile

Many commercial payers start credentialing from your provider’s CAQH profile, now run by DataSpring, the organization formerly called CAQH. Your provider maintains the profile, chooses which health plans can see it and must re-attest it every 120 days, or it expires and credentialing stalls. Fill it in completely before you apply anywhere: license, malpractice insurance and claims history, education, work history with explanations for gaps, practice locations and hours. Then authorize each payer you apply to.

Credentialing and contracting

Apply to each payer through its own process, usually a portal or a request form, and keep a copy of everything you send. Credentialing is the payer checking your provider. Payers that follow NCQA credentialing standards verify licenses and other credentials within a fixed window before the credentialing decision, so an application that stalls for want of one document can force verifications to be redone. Contracting is the business agreement, and it deserves a slower read than most practices give it:

• The fee schedule. Ask for the allowed amounts for the codes you bill most, at least the CMT codes and your office visit codes, before you sign. The guide to setting your fee schedule shows what to do with them.
• Which plans the contract covers. One payer can sell several products. Being in network for one does not always make you in network for all of them.
• Who manages the chiropractic benefit. Some plans hand chiropractic to a separate company, with its own enrollment, claims address and visit rules. The guide to checking coverage before the visit covers how to spot it.
• The effective date. Visits before it are out of network. Ask for the date in writing, and do not assume it is the date you applied.
• Filing and appeal deadlines. Write them down per payer now; you will need them on the first denial.

Plan in months, not weeks. MGMA puts credentialing at 90 to 180 days from application to approval, and in a 2021 poll found payers taking as long as 100 days to set an effective date for a new provider, without allowing claims for the visits in between. Start every payer you plan to take on at once.

BCBS and the BlueCard program

You contract with the Blue plan in your own area. Under the BlueCard program, you file claims for members of Blue plans from other states with that local plan, which routes them to the right plan. The three-character prefix on the member’s ID card identifies the Blue plan or national account behind the coverage. Federal Employee Program members and Medicare Advantage members are handled separately from BlueCard, so ask your local plan how to file for them.

Medicare

Chiropractors enroll in Medicare through PECOS, the online enrollment system: the CMS-855I for each chiropractor and the CMS-855B for a group practice. Reassigning a chiropractor’s Medicare payments to the group, once its own CMS-855R form, now goes on the CMS-855I. Unlike some practitioners, a chiropractor cannot opt out of Medicare and see Medicare patients under a private contract, but can choose to be participating or non-participating. Medicare contractors work to processing standards measured in days to weeks for complete applications, and CMS says online applications tend to move faster than paper ones.

Claims, remittances and payments

A signed contract lets a payer pay you. Three more setups decide whether it can do so electronically:

1. Claims. Your clearinghouse needs your practice set up to send claims to each payer. Some payers require their own enrollment before they accept electronic claims from you.
2. Remittances. Enroll for electronic remittance advice with each payer, usually through your clearinghouse, so the explanation of every payment arrives as a file you can post. The guide to reading an ERA shows what arrives.
3. Payments. Enroll for electronic funds transfer with each payer, into an account the practice controls. For Medicare that is the CMS-588 form. Under HIPAA, a health plan cannot require you to accept virtual card payments, and when you ask for payment by standard EFT the plan has to use it. The guide to matching deposits covers what happens next.

Track it like a project

Enrollment fails quietly: an application sits incomplete for want of one document, and nobody hears about it for a month. Keep one row per payer with the date you applied, what you sent, the reference number, the next follow-up date, the contract and effective date when they arrive, and whether claims, remittances and payments are live. Follow up on every open row every two weeks, and note who you spoke to.

How Claims Native handles enrollment

Once a payer has your provider on file, we set up enrollment with the clearinghouse and the payer so claims and remittances can flow. That takes weeks, and the payer sets the pace; we chase it and tell you where it stands. Your money keeps going to your bank. We never hold it. We start with BCBS commercial plans and add other payers one at a time, once their rules pass our checks.

Sources

• CMS, National Provider Identifier fact sheet. Type 1 and Type 2 NPIs.
• NUCC, Health Care Provider Taxonomy code set. 111N00000X, Chiropractor.
• DataSpring (formerly CAQH), Provider Data Portal resources. Re-attestation every 120 days.
• MGMA, Navigating the credentialing gauntlet.
• MGMA Stat, Credentialing-related denials on the rise in 2021. Effective dates of up to 100 days.
• NCQA, 2025 Health Plan Accreditation policy updates. Credentialing verification time limits.
• Arkansas Blue Cross and Blue Shield, BlueCard program.
• Blue Cross and Blue Shield of Illinois, BlueCard program.
• CMS, Consolidated CMS-855I/CMS-855R enrollment applications.
• CMS, MLN Matters SE1603: Medicare opt-out. Chiropractors may not opt out.
• CMS, Program Integrity Manual transmittal on enrollment processing.
• CMS-588, Electronic Funds Transfer Authorization Agreement.
• CMS, Guidance letter on virtual credit cards, EFT and ERA.