Credentialing with Insurance Companies

by | Dec 30, 2021 | Medicaid, News, Private Insurance, TRICARE

If you are going to accept insurance (including private/employer, Medicaid through the MCOs, TRICARE, etc.), you must be contracted and credentialed with each company.

Sometimes this can be a difficult thing to do as insurance companies may not accept you because they say they have enough providers, even if you are accepted, they may drop you in the culling period they go through each year.

In Virginia, BCBAs operate under their DHP licenses (as an LBA) instead of having their company licensed, as is the case for some other professions in Mental Health.  Once licensed, an LBA can then be credentialed with a number of insurance companies and often the payors will contract with ABA companies rather than just the individual LBA.

To become contracted and credentialed, you will need to contact each insurance company specifically.

A bill in 2020 (HB822 – Head ) was enacted to help providers get paid while in the process of becoming credentialed (so those who need it can get services faster).  Through this bill, payors are required to pay providers for work they have done after all of their paperwork is in and they are just waiting for final approval from the payor.  There are some other specifics outlined below:

B. A carrier that credentials the physicians, mental health professionals, or other providers in its network shall establish reasonable protocols and procedures for reimbursing new provider applicants, within 30 days of being credentialed by the carrier, for health care services or mental health services provided to covered persons during the period in which the applicant’s completed credentialing application is pending. At a minimum, the protocols and procedures shall:

1. Apply only if the new provider applicant’s credentialing application is approved by the carrier;

2. Permit reimbursement to a new provider applicant for services rendered from the date the new provider applicant’s completed credentialing application is received for consideration by the carrier;

3. Apply only if a contractual relationship exists between the carrier and the new provider applicant or entity for whom the new provider applicant is employed or engaged; and

4. Require that any reimbursement be paid at the in-network rate that the new provider applicant would have received had he been, at the time the covered health care services were provided, a credentialed participating provider in the network for the applicable health benefit plan.

Note that the reference to 30 days is how long the insurance company has to pay you after you are credentialed.  It does not refer to the amount of time it takes to be credentialed, or the amount of time for which they will pay you while waiting.

Contact if you have any questions.