Medicare & Medicaid Credentialing: What You Need to Know
In this article, we will discuss the important topic of credentialing for Medicare and Medicaid. We will highlight some key points that providers need to be aware of, including:
You need to credential with each state's Medicaid and Medicare plan in which you hope to bill. This means that if you live on the border of multiple states, you will need to apply for credentialing in each state where you want to see patients.
You cannot bill out-of-state Medicare or Medicaid plans. This means that if you see a patient who is covered by an out-of-state plan, you will not be able to bill their insurance. The patient will be responsible for the cost of care.
If you are an urgent care clinic, you need to be aware of the different Medicare, Medicaid, and Tricare plans that you are contracted with. You cannot bill patients for services that are not covered by their in-network plan.
Even if you are contracted with multiple states' Medicaid and Medicare plans, you still need to educate your staff on how to properly register patients. This is important to ensure that patients are billed correctly and to avoid any issues with claims being denied.
You cannot accept Medicaid plans through a commercial insurance company if you are not participating with the state's Medicaid plan. This means that even if you are contracted with a commercial insurance company that offers an MCO Medicaid plan, you will not be able to bill for those services unless you are also contracted with the state's Medicaid plan.
Some provider types face a heavier Medicare enrollment process than an individual practitioner. Home health agencies enroll through the CMS-855A as institutional providers, which brings a state survey or accreditation through an approved body, an application fee, capitalization requirements, and a change-of-ownership rule that can reset the process entirely. Enrollment is also tied to the agency’s ability to bill at all, since claims cannot be submitted until certification and the provider number are in place, and a gap means services delivered with no path to payment. Sequencing survey, enrollment, and billing setup so they finish together is the part of home health billing services that happens long before the first claim.
Additional Tips:
It is important to start the credentialing process early, as it can take several months to complete.
You can find more information about credentialing requirements on the websites of the Centers for Medicare & Medicaid Services (CMS) and your state's Medicaid agency.
If you have any questions about credentialing, you can contact your state's Medicare contractor or Medicaid agency.
I hope this blog post is helpful! Please let me know if you have any other questions.
