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Contracting with Medicare Advantage Plans: A Guide for Providers

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Contracting with a Medicare Advantage (MCO) plan means becoming an in-network provider for that plan’s members. It’s a process of application, credentialing, negotiation, and contract execution — and it’s different for every plan you join.

This guide walks through the full contracting process.

Step 1: Decide which plans to pursue

You don’t need to join every MCO in your market. Start by:

Analyzing your current patient panel:

  • How many of your current Medicare patients are in Medicare Advantage plans?
  • Which plans are they in? (Check their insurance cards and run eligibility verification)
  • What percentage of your Medicare revenue could move to in-network if you joined those plans?

Analyzing your referral network:

  • Which plans do your referring providers use?
  • If you’re a specialist, which plans are heavily used by PCPs in your area who might refer to you?

Market research:

  • CMS publishes Medicare Advantage enrollment data by county — use it to understand plan market share in your area
  • Ask your local hospital’s provider relations staff which plans have the most local enrollment

Prioritize 3–5 plans to start. Joining too many simultaneously overwhelms your credentialing and administrative capacity.

Step 2: Establish and maintain your CAQH ProView profile

Before contacting any plan, have a current CAQH ProView profile. CAQH (Council for Affordable Quality Healthcare) is the primary source verification platform used by most health plans:

  1. Register at proview.caqh.org if you don’t have a profile
  2. Complete all sections: licensure, malpractice history, work history, training, hospital privileges
  3. Authorize each plan to access your CAQH data
  4. Re-attest every 120 days — set a calendar alert

An expired CAQH attestation is the most common reason MCO credentialing stalls. Keep it current.

Step 3: Contact the plan’s provider relations / contracting team

How to initiate:

  • Most large plans (UHC, Humana, Aetna) have online provider portal applications — start there
  • Regional plans may have a direct phone number for provider contracting
  • Search “[Plan Name] provider credentialing” or “join [Plan Name] network”

What you’ll need to initiate:

  • Your NPI (Type 1 for individuals, Type 2 for groups)
  • Your specialty/taxonomy
  • Your practice address(es)
  • Your EIN

Step 4: Complete the credentialing application

Every MCO runs its own credentialing process. Most use CAQH data as the primary source, with supplementary plan-specific questions:

Typical credentialing requirements:

  • Current state license(s)
  • Active malpractice insurance (minimum coverage amounts vary by plan and specialty)
  • No current OIG exclusion
  • DEA registration (if prescribing)
  • Board certification (for plans that require it for your specialty)
  • Hospital privileges (for some specialties)
  • CAQH profile with current attestation
  • Disclosure of any adverse history

Documents to have ready:

  • Malpractice insurance certificate (current)
  • State license copy
  • Board certification certificate (if applicable)
  • DEA registration (if applicable)
  • Tax ID / EIN documentation (for group applications)

Processing time: 30–90 days per plan. Plans with CAQH integration are faster.

Step 5: Contract negotiation

After credentialing is approved, the plan offers you a participation agreement. This is a contract — read it carefully.

Key contract terms to review:

Fee schedule:

  • What rates will the plan pay for your primary service codes?
  • How does it compare to Original Medicare fee schedule? (Ask for a fee schedule comparison)
  • Is there a rate increase mechanism (annual updates tied to Medicare fee schedule changes)?

Term and termination:

  • Contract term (typically 1 year, auto-renewing)
  • Termination without cause notice period (typically 90–180 days)
  • Termination for cause provisions

Claims submission requirements:

  • Timely filing limits (how many days after service to file)
  • Clean claim submission requirements
  • Electronic vs. paper claims

Prior authorization requirements:

  • Which services require prior authorization under this plan?
  • What’s the turnaround time for PA decisions?
  • What’s the appeals process for PA denials?

Dispute resolution:

  • How do you appeal a denied claim?
  • What’s the timeline for payment disputes?
  • Is there an arbitration clause?

Exclusivity provisions:

  • Are there any provisions limiting your ability to contract with other plans?
  • Are there any “most favored nation” clauses (requiring you to give this plan your best rate)?

⚠️ Most favored nation (MFN) clauses can prevent you from accepting higher rates from other plans. Identify and negotiate these before signing.

Step 6: Execute the contract

Review the final contract with healthcare legal counsel if the contract value is significant or if you’re entering a long-term arrangement. MCO contracts are not standard and have meaningful differences.

After signing:

  • Both parties execute (sign) the agreement
  • The plan enters you into their provider directory
  • Your effective date for patient care is specified in the agreement

Step 7: Go live

Before seeing plan patients:

  • Configure your billing system with the plan’s payer ID and claims submission requirements
  • Train billing staff on the plan’s prior authorization process
  • Verify your listing in the plan’s provider directory
  • Confirm your CAQH profile is still current

⚠️ Risk flags

⚠️ Joining plans without prior auth infrastructure. Plans with heavy prior authorization requirements will generate denials you need to manage. Build the infrastructure before joining.

⚠️ Assuming MCO rates equal Medicare rates. They don’t. Verify the fee schedule for your top service codes before signing. Some plans pay significantly below Medicare; others pay above.

⚠️ Treating plan patients before your effective date. Seeing patients who present with an MCO card before your contract effective date means you’ll be treating out-of-network and the patient faces higher cost-sharing.

⚠️ Not keeping CAQH current. If your CAQH profile lapses, plans may suspend your network status pending re-credentialing.

Questions about MCO contracting? Ask Mae → Free Metolius Health enrollment audit →