Approved isn't paid: what happens after you are accepted into an insurance payer's network

By Kay Ward, founder of Lanyard Health

The approval letter comes in, your new provider is in-network, and somebody tells them they can start seeing that payer's patients. A month later nothing has paid. (Or a paper check shows up and nobody can tell which visits it covers.)

I've done credentialing for 15 years, from typing at an LTAC to running credentialing at Baylor, Sutter and Hartford. Over and over I've watched a practice treat the approval as the finish line while the credentialing person closes the file, and the payment setup falls between two desks.

Approval means the payer let your provider into its network. Getting paid runs on separate paperwork. The payer needs your bank account for deposits and a place to send payment statements, it needs an electronic connection for your claims, and somebody at the payer has to load your provider into its claims system with the right effective date. For most payers none of that sits inside the enrollment application, and a lot of it can't start until the approval letter arrives. Plan on about 30 more days. Your provider can see patients that whole time while the practice collects nothing.

Nobody owns this part

Credentialing teams assume billing handles payment setup. Billers assume credentialing finished it before the provider went live. Billing companies inherit half-finished enrollments all the time and end up owning the bad numbers that come with them.

I've never had a practice ask me how fast they got paid after approval. They ask when they'll be approved, because that's the date the whole industry counts.

Four pieces between the approval and your first payment

  1. EFT (electronic funds transfer). Direct deposit from the payer into your bank account. Medicare won't release payments until it has your EFT form (the CMS-588) on file.

  2. ERA (electronic remittance advice). The electronic statement for each payment, showing what the payer paid and what it adjusted or denied. Without it your biller matches deposits to claims by hand.

  3. EDI enrollment. The connection that gets your claims to the payer. You set it up through your clearinghouse, one payer at a time.

  4. Portal access. Your login to the payer's provider portal, where you check eligibility and claim status. Some payers approve each login one by one.

Each payer runs EFT and ERA its own way. Some take it on their own form or portal, and some send you to an outside payment company (Elevance plans use EnrollSafe, for example). You find out which by checking payer by payer.

Who controls what

  • EFT. You control the bank letter or voided check, the signature and sending the form. The payer controls processing it and switching your payments to deposit.

  • ERA. You pick where the statements go (most practices pick their clearinghouse). The payer turns it on.

  • EDI. You complete your clearinghouse enrollment for that payer. The payer accepts it.

  • Portal access. You request logins for your staff. The payer approves them.

  • Provider loading. You check the effective date and IDs on the approval letter. The payer loads your provider into its claims system.

I don't quote dates for the payer's side (anyone who does is guessing). You can get your side done the same week the approval arrives, and that part is on you.

Signs your provider is stuck in the gap

  • Claims reject at the clearinghouse weeks after the approval. Start with EDI.

  • The payer accepts your claims but no money lands. Check whether EFT went active or is still pending.

  • Deposits come in and nobody can match them to claims. Look at ERA.

  • Claims deny with "provider not on file." The payer hasn't loaded your provider yet, or has the wrong effective date.

  • Paper checks keep coming from a payer you thought you'd set up.

None of these mean the enrollment failed. One of the four pieces is sitting on somebody's desk.

Checklist for the week the approval arrives

  • Save the approval letter and write down the effective date and any provider ID the payer assigned

  • Compare the effective date to the day your provider started seeing that payer's patients

  • Send the EFT enrollment (have a bank letter or voided check ready)

  • Send the ERA enrollment and pick where the statements go

  • Finish EDI enrollment with your clearinghouse for this payer

  • Request portal logins for everyone who needs one

  • Send a few claims and watch them before you release a big batch

  • Check each item once a week until the first payment lands

  • Write down the date the first payment arrives, that's your real finish line

Questions practices ask me

Can my provider see patients before all of this is done?

Yes, once you're past the effective date. You won't see payment for those visits until setup is done, so watch each payer's timely filing limit while you wait.

Doesn't my biller handle this?

Some billers set up EDI and ERA through the clearinghouse. EFT needs the practice's bank details and a signature from someone at the practice. Ask who owns each piece, and get the answer in writing.

Do I have to do this for each payer?

Yes, for each payer, and for some payers each plan.

Does enrollment take long before this part even starts?

Payer enrollment runs four to six months for most practices, and the payer's review takes up most of that.

Is it normal that nobody warned me?

Yes. Most of the industry counts approval as done, so practices find out about the rest when the money doesn't show up.