Managed Care Organization - MCO

An MCO provider agreement sets reimbursement, prior-authorization rules, billing workflows, and risk allocation between a healthcare provider and a health plan. In practice, credentialing typically takes ~60–120 days, so activation should be tied to payer approval dates. Revenue flow hinges on clean billing: top performers keep clean-claim rates ≥95% (often ~98%), which supports prompt-pay windows of ~30 days for electronic claims and ~45 days for paper. Prior-authorization timelines are tightening—many regulated lines now require decisions within 72 hours (urgent) or 7 days (non-urgent). Meanwhile, initial denial rates can run ~14–19% depending on the line of business, underscoring the need for clear appeal ladders. Want a plug-and-play contract plus a rate-negotiation checklist for your specialty? Call 0977 523 155 and we’ll tailor it to your payers and state rules.