Provider Enrollment
Provider enrollment is the administrative process of registering a healthcare provider with a payer to establish the right to submit claims and receive reimbursement — distinct from credentialing, which verifies clinical qualifications.
What is Provider Enrollment?
Provider enrollment is the administrative process through which a healthcare provider registers with a payer — Medicare, Medicaid, or commercial insurers — to obtain the right to bill for services and receive reimbursement. It is administratively distinct from credentialing (which verifies clinical qualifications) but operationally sequential: providers must be credentialed before they can be enrolled. For Medicare, all providers billing fee-for-service Medicare must be enrolled in PECOS (Provider Enrollment, Chain, and Ownership System). Enrollment types include individual provider enrollment (CMS Form 855I), group practice enrollment (CMS Form 855B), and institutional provider enrollment (CMS Form 855A). Medicare enrollment timelines are 30–90 days for individual providers and 60–120 days for group practices. A critical and often underutilized feature of Medicare enrollment is 27-month retroactive billing — Medicare allows new providers to bill retroactively for up to 27 months of services once enrollment is complete, making early initiation of the enrollment process financially essential. Medicaid enrollment is entirely separate from Medicare and is administered by each state individually — practices operating across multiple states face exponential enrollment complexity with no shared infrastructure. Medicare revalidation is required every 5 years for physicians and every 3 years for institutional providers.
Why It Matters for Healthcare Analytics
Enrollment gaps — whether from a new provider awaiting approval or an existing provider missing a revalidation deadline — result in claim denials that cannot be retroactively recovered beyond Medicare's 27-month window. Tracking pending enrollment applications by aging, monitoring revalidation deadlines, and identifying retroactive billing opportunities for newly enrolled providers are revenue cycle functions with directly quantifiable financial impact.
How Vizier Tracks Provider Enrollment
Upload your provider roster and enrollment status data, then ask "Which providers have enrollment pending with Medicare for more than 60 days and how much retroactive revenue is at stake?" — Vizier tracks enrollment status and aging by provider and payer, and calculates retroactive billing opportunities for newly approved providers.