Enrollment types

Healthcare providers must complete three distinct enrollment processes to work with payers and send transactions through clearinghouses:

• Credentialing: Validating a healthcare provider’s qualifications
• Payer enrollment: Registering a credentialed provider with a specific payer’s health plan(s)
• Transaction enrollment: Registering a provider to send and receive EDI transactions (such as claims and eligibility checks) through a specific clearinghouse with a specific payer

These enrollments typically happen in sequence: first credentialing, then payer enrollment, and then transaction enrollment, although credentialing and payer enrollment are sometimes combined into a single process. Stedi specifically handles transaction enrollment, the final step needed to exchange eligibility and claims transactions through our clearinghouse.

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Credentialing

Credentialing is the process of validating a healthcare provider’s qualifications, including:

• Verification of education, training, and licensure
• Review of board certifications and medical specialties
• Confirmation of work history and malpractice insurance
• Review of any sanctions, restrictions, or malpractice claims

Credentialing establishes that a provider meets the payer’s standards for providing care to their members. Once credentialed, a provider becomes eligible to join the payer’s networks. Some payers have multiple networks and those networks may contain multiple tiers of providers. In order to actually join a network, the payer may require the provider to agree to a rate schedule and sign a contract with other terms.

Timeline: Credentialing typically takes 90-180 days to complete.

Who handles it: Providers must complete credentialing directly with each payer or through a specialized credentialing service. Stedi doesn’t handle the credentialing process.

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Payer enrollment

Payer enrollment (also called provider enrollment) is the process of registering a credentialed provider with a specific payer’s health plan(s). This involves:

• Submitting applications to payers for specific lines of business (Medicare, Medicaid, commercial plans)
• Providing information about the provider’s practice, such as locations and billing details
• Establishing contract terms for services and reimbursement rates
• Setting up payment arrangements

Payer enrollment establishes a business relationship between the provider and the payer. Once enrolled, the provider can submit claims to the payer and receive payments for services provided to the payer’s members. (Payers might also accept at least certain types of claims from non-enrolled providers subject to legal requirements and plan rules.)

Timeline: Payer enrollment typically takes 60-120 days after credentialing is complete. However, this process is sometimes combined with or conducted in parallel with the credentialing process.

Who handles it: Providers must complete payer enrollment directly with each payer. Stedi doesn’t handle the payer enrollment process.

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Transaction enrollment

Transaction enrollment is the process of registering a provider to send and receive electronic EDI transactions (such as claims and eligibility checks) through a specific clearinghouse with a specific payer. This involves:

• Submitting the provider’s name, tax ID (EIN / TIN), NPI, billing address, and contact information
• Specifying which transaction types (e.g., claims, eligibility checks, ERAs) the provider wants to exchange electronically
• Setting up the necessary technical connections between the clearinghouse and payer

Once enrolled, the provider can send and receive specific transactions with the payer through the clearinghouse.

Timeline: Transaction enrollment typically takes 2-6 weeks, depending on the payer.

Who handles it: Stedi handles the transaction enrollment process on behalf of providers. Visit Transaction enrollment to learn how to complete transaction enrollment through Stedi.