Insurance credentialing for therapists and group practices

Credentialing and contracting are two different steps

Credentialing is the payer’s check of the clinician, and contracting is the agreement that puts the clinician in network. NCQA, the National Committee for Quality Assurance, describes credentialing as a detailed review. It covers a practitioner’s license, medical education, history of sanctions, prior malpractice cases and other information. Contracting sets the rates and terms between your practice and the payer. The order of the two steps varies by payer, and Aetna’s published process is one example. Once you request participation, Aetna checks the current need for providers in your area and decides whether contracting or credentialing applies. After contracting, it pulls your credentialing application from CAQH ProView, if credentialing applies. When credentialing is complete, the contract is finalized. An NPI is separate from both. CMS says having an NPI doesn’t mean a provider is credentialed, and it doesn’t enroll a provider in a health plan.

The steps to get a therapist in network

Whether you do it yourself or use a mental health credentialing service, the steps are the same. A therapist needs an NPI, a CAQH profile, an application and a contract with each payer. Medicare enrollment comes on top if you bill Medicare. Each payer sets its own forms, order and timeline, so use these steps as a checklist for each clinician.

1. Get an individual NPI

   The clinician applies for a Type 1 NPI through NPPES, the CMS system that issues NPIs. Health plans require NPIs on claims and other transactions, and each person can hold only one.

2. Complete the CAQH profile

   The clinician enters professional and practice information in the CAQH Provider Data Portal, formerly ProView. It’s free for providers.

3. Authorize each payer

   Payers that read applications from CAQH need permission to view the profile. Aetna, for example, asks providers to name it as an authorized health plan.

4. Apply to each payer

   The practice requests participation with each insurer it wants to join. A payer may first check whether it needs more providers in your area, as Aetna does.

5. Credentialing review

   The payer verifies the clinician’s license, education, sanctions and malpractice history.

6. Contract and effective date

   The contract is finalized. Confirm the effective date in writing before booking that payer’s members with the clinician.

7. Medicare, if you bill it

   The clinician enrolls through PECOS and can reassign benefits to the group, so the practice can bill Medicare for their sessions.

Type 1 and Type 2 NPIs in a group practice

A group practice set up as a corporation or partnership uses two kinds of NPI. CMS issues Type 1 NPIs to individual providers, including sole proprietors. Type 2 NPIs go to health care organizations, such as physician groups.

• An incorporated clinician can hold both, one for themselves and one for their corporation or LLC.
• CMS’s Medicare enrollment form for clinics and group practices requires a Type 2 NPI.
• Changes to NPI information must be reported within 30 days, and an NPPES update doesn’t change Medicare enrollment on its own.

From new hire to first paid claim

For a group practice, credentialing is the step between hiring a clinician and billing their first in-network session. The start date and the first in-network claim are two different days. Before the start date, the clinician needs a Type 1 NPI and a complete, attested CAQH profile. Each payer your practice contracts with also needs an application, which it reviews on its own schedule. A payer may decide it doesn’t need more providers in your area. Until a payer confirms the clinician is in network, the clinician can’t see that payer’s members as in-network clients. That affects intake as much as billing. New clients should be offered clinicians who are in network for their plan. An existing client moving to the new clinician needs their plan checked first. Tracking each application by payer, with its status and effective date, keeps the schedule and the claims in step.

Staying credentialed after approval

Approval starts three separate renewal cycles, and the Medicare one applies only if you bill Medicare. If a CAQH attestation lapses, the profile’s status changes to Expired. We manage renewals and track status for each clinician.

Pre-licensed and supervised clinicians

Pre-licensed clinicians raise the hardest credentialing questions for a growing group, and the answer depends on the payer.

For Medicare, CMS spells out the rules. Marriage and family therapists and mental health counselors can enroll once they’re licensed or certified by the state. They also need at least 2 years or 3,000 hours of post-master’s supervised clinical experience. Medicare allows incident-to billing as well. Under it, the supervising physician or other listed practitioner bills for behavioral health services that auxiliary personnel provide under general supervision. Check with your Medicare contractor which clinicians qualify before you rely on it.

Commercial payers each set their own policy on whether a supervisor can bill for a pre-licensed clinician’s sessions. Check each payer’s policy and your contract before booking insured clients with a pre-licensed clinician.

Where your contracts allow it, we set up and maintain supervisory and incident-to billing under them. License and supervision are among the matching criteria your practice sets for intake, so the clinician options a new client sees can reflect them.

Keep your contracts in your practice’s name

Whose name is on a payer contract decides what the practice keeps. When your practice holds its own contracts, the rates and the relationship with each payer belong to the practice.

Some practices bill through a network platform instead. Before joining or leaving one, check whose contract and tax ID each claim goes out under. Our guide to network platforms and independent practice walks through the questions to ask.

Cortexa is not a network platform and doesn’t bill under contracts of its own. When we credential a clinician, the application is for your practice’s contracts, and they stay in your practice’s name.

How credentialing connects to intake and billing at Cortexa

Cortexa is an operations team for independent therapy practices that runs the front desk, intake, billing, credentialing and payroll as one team. The same team that books new clients and files claims does the credentialing. State licensing stays with your practice.

1. We apply and track

   We manage new applications and renewals for your clinicians and track status with each payer.

2. Intake matches

   Insurance, license and supervision are among the matching criteria your practice sets. The client chooses the clinician.

3. Intake verifies

   We verify insurance eligibility and in-network status at intake, before the first session.

4. Billing follows through

   We file claims after sessions and follow every claim until it’s paid.

What credentialing costs

Credentialing is passed through at our actual documented cost. It’s part of the Full Service Partner membership, where billing runs about 3% of what you collect. We agree the exact scope and rate before you start, and you can start with only the work you need most. Practice Analytics is included at no extra cost.

Some of the underlying steps carry no fee of their own. DataSpring, the company formerly called CAQH, says providers use its portal free of charge. CMS says marriage and family therapists and mental health counselors don’t pay a Medicare enrollment application fee.

Once a clinician is in network, our mental health billing service picks up from the first claim.