Provider Enrollment and Credentialing in Medicaid

Chapter 7 looks at Medicaid provider enrollment and managed care credentialing, which is designed to ensure that Medicaid enrollees receive care from qualified providers. In addition, these processes are intended to prevent the enrollment of providers who have criminal records related to federal health programs or who have engaged in fraud, waste, or abuse. The chapter provides an overview of federal requirements for provider enrollment and credentialing in Medicaid, the approaches taken by three states, and challenges for states and providers. It includes insights into barriers faced by certain provider types or challenges related to specific parts of the enrollment and credentialing processes as well as their effects on provider participation, state administrative burden, and program integrity.