A closed panel is a health plan saying it has enough providers of your type in your area and will not add more. No federal law makes a plan accept every provider, so a closed panel is usually lawful. It is also often not the end of the story.
Plans have to give a written reason, meet network adequacy standards for time, distance and appointment waits, and, in some states, decide credentialing applications by a deadline. Where a plan’s network falls short, a documented case can change its answer.
Which rules reach which plan
| Plan type | What the plan may do | What a provider can use |
|---|---|---|
| Medicare Advantage | A plan may refuse providers beyond the number its enrollees need (42 CFR 422.205(b)(1)), except a private fee-for-service plan. It must give written notice of the reason when it declines a provider (422.205(a)). | A written reason, the network adequacy evidence, and a request to reconsider. Hearing rights under 422.202(d) cover suspensions and terminations, not first-time applicants. |
| Medicaid managed care | A plan may also decline providers it does not need (42 CFR 438.12(b)(1)) and must give written notice of the reason (438.12(a)(1)). Each state sets one credentialing policy for its plans (438.214). | The state’s network adequacy standards (438.68), and the rule that a plan must cover care out of network when its network cannot provide it (438.206(b)(4)). |
| Commercial plans under state law | State law applies to insured plans. A few states have any willing provider laws; many states set credentialing deadlines and network adequacy standards. | The state’s credentialing deadline, provisional credentialing rule and adequacy standards, and a complaint to the insurance department framed as an adequacy or statutory failure. |
| Self-funded employer plans | Federal ERISA governs these plans, and state insurance law does not reach them. Federal law (PHSA 2706(a)) does not require any plan to contract with every willing provider. | The plan’s own provider terms, and the network the plan rents, which may be an insured network subject to state rules. |
States with an any willing provider law
These laws are rare and narrow, and none reaches a self-funded employer plan. Check what each one covers.
- ArkansasCovers providers broadly
- GeorgiaLimited to some plans or providers
- IdahoLimited to some plans or providers
- KentuckyCovers providers broadly
- MarylandLimited to some plans or providers
- MinnesotaLimited to some plans or providers
- South DakotaCovers providers broadly
- TexasLimited to some plans or providers
- UtahLimited to some plans or providers
- VirginiaLimited to some plans or providers
- WyomingLimited to some plans or providers
From rejection to contract in three steps
- Step 1
Rejection review
$249, credited toward a dispute
Why the plan said no, whether it was a credentialing denial or a full network, which rules reach that plan type in your state, which deadlines are running, and a written plan.
- Step 2
Dispute and escalation
$799 per payer, or $1,999 for three
The reconsideration request, the access-gap evidence, the letters and, where the law supports one, a regulator complaint, all prepared for you to sign and send. We track every deadline and response.
- Step 3
Win and onboarding
A flat $1,500 per win, only on a win
A contract, a credentialing approval or a single-case agreement. Enrollment then passes to our White Glove Credentialing sister team.
Questions
- Is a closed panel legal?
- Usually, yes. Federal rules let Medicare Advantage and Medicaid managed care plans decline providers beyond the number their enrollees need, and most states have no broad any willing provider law. What a plan must do is give a written reason and meet the network adequacy standards that apply to it.
- Does a closed panel mean the answer is final?
- Not always. A plan’s network can fall short in a specialty, a language or a county, and the plan has to meet adequacy standards there. Documented gaps, a provider who joins a participating group, and a plan’s own reopening dates all change the answer.
- Do you represent me or send the dispute for me?
- No. We are not a law firm and do not represent providers or give legal advice. We research the rejection and prepare the request, the evidence and the letters; you sign and send them. When a matter needs a lawyer, we say so and you hire a healthcare attorney directly.
- How does the win fee work?
- It is a flat fee charged only when a payer offers you a contract or approves your credentialing after a dispute: $1,500 per win, or $1,250 per win in a three-payer bundle. It is never a share of what you bill.
Sources: 42 CFR 422.205, 422.202, 438.12, 438.206, 438.214. General information, not legal advice. Not affiliated with CMS, any health plan, NCQA or any state agency.