Credentialing and Contracting 101 - What You Need to Know

Are You Venturing Out On Your Own? Here Are Some Things to Know Before You Start the Credentialing & Contracting Process.

Have you thought about or decided to venture out on your own? Whether you plan on doing some independent contracting work for yourself or opening up an agency, you will need to take certain steps with the insurance companies to get you successfully credentialed and contracted.

What is Credentialing and Why is it Important?

Credentialing pretty much means "the process of getting the provider(s) loaded into the insurance companies system". For claims to be processed for reimbursement and authorizations to be approved, you must first be credentialed in the insurance company's system.

What is the Difference Between Credentialing and Contracting?

These two terms are usually used indeterminately (I mean.. I do it too), but technically these are two separate things. As I mentioned above, being credentialed means the provider(s) is loaded into the insurance company's system. Normally when you are only credentialed, it means you are out of network with the insurance company. Now, contracting is the process of becoming in network with the insurance company. Being a contracted provider means you have a fully executed contract between yourself (or group), and the insurance company.

How Do I Know if I’m Already Credentialed or What my Status is?

You should contact the insurance company directly. Have your individual NPI number ready and ask them if you are a credentialed provider. If you are, you can ask them if you are credentialed under a group contract or if you have an individual contract. This is important information to know.

What is the Difference Between an Individual Contract and a Group Contract?

A Group contract is where your agency “group” is contracted with the insurance company. With group contracts, you can credential providers and have them listed under your group contract. This is the best contract to obtain (if possible) because the contract will stay with your group indefinitely.

Now, some insurance companies only allow individual contracts (based on criteria, let's use Cigna/Evernorth as an example). If you individually contract your BCBA’s to provide services and link them to your group, if they decide to leave your agency for new employment, the contract will go with them and you will no longer have a contracted Cigna provider. Again, this is not ideal but some insurance companies do not allow group contracts.

What should I have before I start the credentialing process for my new agency?

• Completed CAQH profile

• Type 2 (group) NPI number

• Company TIN (tax Id number)

• Professional Liability Insurance (minimum $1 million/$3 million coverage)

• Business address (changing your address in the middle of credentialing and contracting can significantly delay processing time from the insurance company.)

• Business email

• Phone and Fax number

• Business Bank Account

What is a CAQH profile?

A CAQH profile is a free online profile that insurance companies use to credential and re-credential providers. If your provider does not have a CAQH profile, they are required to have one before starting the credentialing and credentialing process, as many insurance companies require that the provider have a CAQH profile as part of the credentialing process. This profile is unique to each provider and will stay with them as long as they practice. Please be sure that your provider knows to keep their CAQH login information in a safe spot.

Note: Most insurance companies only require BCBAs to have a CAQH profile.

Here is the link to the CAQH website: https://proview.caqh.org/Login/Index?ReturnUrl=%2f

What is a type 2 NPI?

A type 2 (group) NPI is an individualized number assigned to you from the NPPES registry. I like to describe it as being similar to your social security number as a unique identifier, but it is a public number. This NPI will be assigned to your agency specifically and not to a specific provider. You can apply for your type 2 NPI by logging into the NPPES website.

Here is the link to the NPPES website: NPPES (hhs.gov)

Ashley Adams

President & Co-Owner of Spectrum ABA Billing