Sample: Payor Discovery Report
Executive Summary
Based on our comprehensive payer discovery, we have identified four payors ready for immediate pursuit and one that requires additional access or information before proceeding. Below is the breakdown of your optimal path forward:
The following payors are currently open for enrollment and can be pursued without delay:
BCBSM / BCN — Group enrollment required before the provider can be linked.
Priority Health — Network closed to new providers, but reassociation permitted for this provider.
Aetna — Network open; new application required via CAQH and Aetna portal.
UHC / Optum — Network open; no minimum group size; application can proceed directly.
Total Payors Ready to Pursue Now: 4
The following payor requires additional access before enrollment can proceed:
Michigan Medicaid— Provider is enrolled, but CHAMPS access is needed to confirm status and begin group credentialing and MCO affiliations.
Total Payors Requiring Additional Research: 1
Payor Report: BCBSM / BCN
Ready to Pursue
Enrollment Pathway Group enrollment is required and must be completed through the Availity portal. Once the group is credentialed, the provider can be linked to the TIN for participation.
Delegated Credentialing No delegated credentialing pathway is applicable for this provider type.
Telehealth Coverage Occupational therapy services are covered under some BCBSM/BCN commercial plans. Coverage should be verified per plan before offering telehealth services.
Retroactive Billing Policy May be granted from the credentialing approval date but is not guaranteed.
Action Required Submit the group application via Availity, including required legal documents. Prepare provider documentation for linking after group approval.
Fee Schedule Visibility 📉 Low — Fee schedules are not disclosed until after contract execution.
Risk Rating ⚠️ Moderate — The process is standard, but delays are common if documentation (e.g., group NPI, malpractice) is incomplete.
Maintenance & Oversight Site visits may be required for providers offering home-based care. Recredentialing occurs every 3 years and providers must complete annual updates via Availity. Denials often result from outdated malpractice insurance, incomplete credentialing forms, or failure to maintain portal updates.
Payor Report: Priority Health
Ready to Pursue
Enrollment Pathway New enrollments are currently closed. However, this provider is already in-network under another TIN, and reassociation to the new group is allowed through the portal.
Delegated Credentialing No delegated credentialing arrangements apply.
Telehealth Coverage OT services are supported. Confirm network participation before submitting telehealth claims.
Retroactive Billing Policy Not applicable due to reassociation structure.
Action Required Initiate the TIN reassociation request through the Priority Health portal using the provider’s current credentials.
Fee Schedule Visibility 📊 Medium — Fee schedules may be requested after reassociation is processed.
Risk Rating ⚠️ Low — Straightforward reassociation if accurate information is submitted.
Maintenance & Oversight Site visits are not typical unless flagged during review. Recredentialing is required every 3 years. Denials typically result from submitting the incorrect application type (e.g., new instead of reassociation) or outdated supporting documents.
Payor Report: Aetna
Ready to Pursue
Enrollment Pathway Individual enrollment is permitted for solo providers. A group contract is available for two or more providers and includes a separate process.
Delegated Credentialing Aetna does not require delegated credentialing for OT providers.
Telehealth Coverage Telehealth services, including OT, are supported by Aetna commercial plans. Verify plan-level eligibility prior to billing.
Retroactive Billing Policy Retroactive billing may be allowed from the date of submission if requested and approved during enrollment.
Action Required Ensure the provider’s CAQH profile is attested and up to date, then submit Aetna’s Medical Request for Participation via the portal.
Fee Schedule Visibility 📈 High — Fee schedules are accessible via Availity once the provider is registered.
Risk Rating ⚠️ Moderate — A common source of delay is failure to keep CAQH attested or submit all necessary supporting documentation.
Maintenance & Oversight Site visits may be required for home-based providers. Recredentialing occurs every 3 years, and CAQH attestation must be completed quarterly. Denials are typically due to incomplete or outdated documents, work history gaps, or license mismatches.
Payor Report: UHC / Optum Physical Health
Ready to Pursue
Enrollment Pathway UHC allows both group and individual enrollment. No minimum provider count is required. Applications are submitted through the UHC portal.
Delegated Credentialing No delegated credentialing arrangements apply.
Telehealth Coverage Coverage is available but varies by plan. Plan verification is required before billing for remote services.
Retroactive Billing Policy May be available depending on region and plan approval; confirm during application submission.
Action Required Prepare all documentation, including W-9, attestation, insurance, and licensure, then submit via the UHC provider portal.
Fee Schedule Visibility 📈 High — Fee schedules are available for contracted providers within the portal.
Risk Rating ⚠️ Moderate — While the process is accessible, delays are often due to missing attestations or supporting forms.
Maintenance & Oversight Site visits are sometimes required for home health or mobile providers. Recredentialing occurs every 3 years. Denials most often result from incomplete application packages, invalid malpractice coverage, or unverified background information.
Payor Report: Michigan Medicaid
Research Required
Enrollment Pathway The provider is currently enrolled with Michigan Medicaid, but access to CHAMPS is required to confirm active status. Group enrollment is allowed with no minimum provider count. MCO credentialing is separate and must be confirmed individually.
Delegated Credentialing Unconfirmed — some Medicaid MCOs may require delegated pathways. Verification is needed with each plan.
Telehealth Coverage Telehealth services are generally covered for OT under Michigan Medicaid.
Retroactive Billing Policy Cannot be determined until enrollment status and MCO credentialing are confirmed.
Action Required Obtain CHAMPS login credentials and confirm enrollment status. Begin group enrollment and contact each MCO individually.
Fee Schedule Visibility 📊 Medium — CHAMPS provides access to general rates; individual MCOs vary.
Risk Rating ⚠️ High — Current lack of access to CHAMPS and MCO-specific credentialing steps may delay enrollment.
Maintenance & Oversight Home-based providers may be flagged for site verification depending on MCO policy. Revalidation frequency varies (3–5 years). Denials often occur due to lack of access to the CHAMPS portal, outdated contact information, or unlinked NPI-to-group records.
Legend / Key
Fee Schedule Visibility Scale:
Poor: Fee schedules are not accessible or only available after enrollment is complete.
Fair: Limited access, such as by request or through a portal after contract execution.
Good: Generally accessible via portal or upon request after credentialing.
Excellent: Public or easily accessible before or during the contracting process.
Risk Rating Scale:
Low: Routine process with minimal barriers or delays expected.
Moderate: Some known issues or extra documentation needed; delays possible.
High: Significant barriers, unclear requirements, or frequent delays likely.
Critical: Major obstacles or high likelihood of denial or extended delays.
Maintenance & Oversight Includes site visit requirements, credentialing maintenance frequency, and common application or revalidation pitfalls
Last updated