Credentialing With Medicare Advantage Plans: What Differs From Original Medicare

A family medicine practice hired a nurse practitioner who started in March. The credentialing coordinator did the right things: PECOS application in January, Medicare approval with a retroactive effective date, Medicaid enrollment, CAQH profile attested. In April the first remittances came back from three Medicare Advantage plans: CO-242, services not provided by network or primary care providers. The practice manager's question was reasonable. "She is enrolled in Medicare. Aren't these Medicare plans?"

They are Medicare plans in the sense that Medicare pays them. They are private insurers in every sense that matters for credentialing. Being enrolled in Original Medicare gives a provider no network status with any MA plan, and each plan runs its own contracting and credentialing process with its own committee calendar. Roughly half of Medicare beneficiaries are now in MA plans, so for most practices this is not a side issue.

Key takeaways

• Medicare enrollment through PECOS and MA network status are two different things. The first is decided by the MAC; the second by each plan's credentialing committee and contract.
• An MA plan relationship has two parts, credentialing and contracting, and a provider can be approved by the committee and still not payable because the roster or claims system was never loaded.
• Medicare backdates an effective date up to 30 days before the application; most MA plans do not backdate at all, so the gap between start date and MA effective date is real revenue at risk.
• Start MA applications 90 days before the provider's start date, rank plans by revenue, and ask every plan for its committee date and file cutoff.
• Track days from application to effective date by plan so you know each plan's real timeline, not its stated one.

Original Medicare versus Medicare Advantage: the differences that matter

Two steps, not one: contracting and credentialing

The step most practices miss is that an MA plan relationship has two parts. Credentialing is the plan's verification of the provider's license, training, malpractice history and work history, and it results in committee approval. Contracting is the agreement between the practice (the group, under its TIN) and the plan, with a fee schedule. A provider can be credentialed by a plan and still not be payable because the group's contract does not list the location, the provider was never added to the roster, or the plan's claims system has not been loaded. When a plan says "approved", ask three questions: approved by the committee, loaded to the contract, and loaded to claims, with the effective date of each.

Many MA plans credential providers through the same process and committee as the carrier's commercial products. If the practice is already in network with the carrier's commercial plan, adding the MA product is usually a contract amendment rather than a new credentialing file, but only if someone asks for it. Plans do not add products automatically.

Delegated credentialing

Practices that belong to an independent practice association, a clinically integrated network or a large medical group are often credentialed by that organization under a delegation agreement with the plan, rather than by the plan itself. This is faster when it works, because the delegated entity controls the committee calendar. It fails when the practice assumes the IPA has handled the plan and the IPA assumes the practice applied directly. Ask the IPA for the list of plans it holds delegation for, and treat every plan not on that list as a direct application.

The preclusion list

Since January 1, 2019, CMS has maintained a preclusion list of providers and prescribers who are barred from receiving payment for MA items and services and Part D drugs, mainly because they were revoked from Medicare or engaged in conduct that would have led to revocation. MA plans must deny payment for services from precluded providers. This replaced an earlier proposal to require every MA provider to enroll in Medicare, which CMS withdrew. The practical point for practices: MA plans will screen your providers against the list, and a provider with a Medicare revocation in their history needs that resolved before an MA application will succeed.

The sequence for a new provider

1. Before the start date (90 days out if possible). Complete the CAQH profile and authorize each MA plan to view it. Confirm the group's contract with each carrier lists the product lines (commercial, MA, exchange) and the locations where the new provider will work.
2. Medicare first. Submit PECOS as soon as the provider has a start date. MA plans do not require Medicare enrollment as a rule, but the retroactive effective date protects Original Medicare revenue while the MA files move.
3. Rank the MA plans by revenue. Submit the two or three that matter most first. Record the submission date and reference number for each.
4. Ask about the committee calendar. A plan whose committee meets on the second Tuesday of each month, with a file cutoff ten days earlier, has a predictable approval date. Missing the cutoff by a day costs a month.
5. Follow up every two weeks. Ask the same three questions each time: is the file complete, when is committee, and what is the contract load date after approval.
6. When approved, load the effective date into the billing system the same day and release held claims. Confirm the provider appears in the plan's online directory, because directory accuracy is now a CMS requirement for plans and a directory error is often the first sign of a roster problem.

What the gap costs

Back to the nurse practitioner who started in March. Say she sees 18 patients a day, 40% of them Medicare beneficiaries, and half of those are in MA plans. That is about 3 to 4 MA patients a day, or roughly 75 a month, at an average allowed amount around $95 for the visit mix. If the three main MA plans reach their effective dates in mid-June, the practice has about three and a half months of MA visits, roughly $25,000 in charges, that are either denied CO-242, held, or rescheduled to other providers. Some of that is recoverable if a PPO pays out of network; most of it is not. Starting the MA files in December instead of March, and asking each plan for its committee cutoff, would have moved the effective dates to roughly the start date and kept most of that revenue.

Scheduling around the gap

For the weeks between the provider's start date and each plan's effective date, schedule MA patients of that plan with providers who are already in network, and route the new provider's early appointments to Original Medicare, commercial and plans that have approved. Where a PPO plan allows out-of-network payment at Medicare rates, confirm the patient's benefits before the visit and tell the patient about any higher cost sharing. HMO MA patients should not be seen by the new provider until the effective date unless the plan has authorized it. Billing under another provider's number to bridge the gap is not a workaround; it is a compliance problem.

This takes a scheduling rule, not a memo. Most practice management systems can flag a provider as "not credentialed" for specific payers so the scheduler sees a warning when booking. Set it up on day one and remove each payer as its effective date arrives. The alternative is a front desk that remembers the rule for a week.

Numbers to watch

Days from application to effective date, by plan, tracked over time so you know each plan's real timeline rather than its stated one. Denials with CARC CO-242 and CO-B7 (provider not certified or eligible for this service on this date) by provider, which show up when a claim is submitted before the load date. And the count of providers whose recredentialing date falls in the next six months, because a lapsed MA recredentialing stops payment as surely as a failed initial application.

Revelrex credentialing and provider enrollment handles MA plan applications alongside Medicare and commercial files, with committee dates and load confirmations tracked per plan. Rates are on the pricing page.

Questions we hear

Can the plan backdate the effective date to the provider's start date?

Some plans will backdate to the date of a complete application, and a few will backdate to the start date if asked at contracting. Most will not, and none are obliged to. Ask before the file is submitted; asking afterwards rarely works.

We are in network with the carrier's commercial plan. Why were the MA claims denied?

Because the MA product was never added to your contract or the provider was never loaded to the MA roster. Ask the carrier's provider relations contact for a roster report by product line and compare it with your provider list.

Do MA plans require a separate Medicaid enrollment for dual eligible patients?

Dual eligible special needs plans and Medicaid managed care crossover claims depend on the state. In many states the provider must also be enrolled in Medicaid for cost sharing to be paid, so treat Medicaid enrollment as part of the MA sequence if your practice sees dual eligible patients.

What to do this month

1. List every MA plan you bill, with the product line status on your contract (commercial, MA, exchange) and the roster of providers loaded for each.
2. For any provider hired in the last year, pull denials with CO-242 and CO-B7 by payer and confirm each plan's effective date matches what the billing system holds.
3. Ask each of your top three MA plans for its credentialing committee schedule and file cutoff, and write them into the onboarding checklist.
4. Ask your IPA or network, if you have one, for the list of plans it holds delegated credentialing for.
5. Set up the "not credentialed" payer flag in scheduling for every provider with an open MA file.