How to Get Credentialed with Medicaid Managed Care Plans as an ABA Provider

Insurance credentialing is a vital first step in an ABA practice’s revenue cycle management (RCM). Before taking on clients, clinicians must be credentialed, verifying they meet the insurance provider’s requirements to deliver ABA therapy. Let’s break down the process of insurance credentialing. 

Credentialing is the process of verifying with an insurance or Medicaid provider that the BCBA or other clinician meets their minimum requirements to provide a specific service. Any provider who wants to provide ABA therapy to Medicaid recipients must become credentialed with Medicaid. 

When you submit an insurance credentialing application, the payor will consider several factors, including the clinician’s:

• Education
• Certifications
• Licensure
• Work history
• Background check

Medicaid Managed Care Organizations (Medicaid MCOs) are private insurance companies contracted by state Medicaid programs to manage the benefits and delivery of services for Medicaid recipients. 

State Medicaid programs provide funding and establish primary requirements, while the MCO handles the administration and delivery of the services. ABA providers must be credentialed with Medicaid before providing services to those with Medicaid MCO plans. However, it’s important to keep in mind that getting credentialed with Medicaid doesn’t automatically grant them access to MCO plans. Providers must be individually credentialed with each MCO. 

Every insurance company has its own application process to get credentialed, so the most important thing is to check the specific requirements with each funder. You’ll need to complete separate applications for every funder, including individual MCOs. However, before you submit a credentialing application with a Medicaid Managed Care Organization, you must be credentialed with Medicaid, so that’s the first step. Let’s break down the process of applying to get credentialed with Medicaid and private insurance providers.

Before you start the Medicaid or insurance credentialing process, you’ll need to make sure you have a few things in order, including:

• Apply for an NPI number.  If you don’t already have one, apply for a National Provider Identifier (NPI)  number. You’ll need this to enroll with insurance providers and bill for services. Individual providers need a Type 1 NPI while organizations require a Type 2. 
• Create and complete a CAQH provider profile. A majority of insurance providers use CAQH to simplify and streamline the credentialing process, so make sure your CAQH profile is accurate and up-to-date. 
• Verify your insurance meets minimum requirements. Make sure you have liability and malpractice insurance that meets the funder’s requirements. 
• Prepare supporting documentation. Gather documentation you may need for the application, including your resume, proof of insurance, certification, and licensure.

Most providers have an online portal for credentialing applications. Again, make sure everything is accurate and free of errors before submitting.

Credentialing can take some time. Don’t begin offering services until approval is received. 

Getting credentialed with a Managed Care Organization can vary from company to company, but it typically takes 1-4 months. You can increase your chances of getting approved sooner by ensuring your application is error-free and complete with any supporting documentation needed. 

According to the Centers for Medicare and Medicaid Services (CMS), ABA providers must revalidate their enrollment at least once every 5 years. However, many states require providers to reenroll every 3 years, so make sure you know your state’s specific guidelines. 

Becoming credentialed is only the first step. To be able to depend on agreed-upon rates and other terms, you’ll also need to complete the contracting process. Once you’re both credentialed and contracted with an insurance provider or MCO, you can begin delivering services and billing for care provided to their members. Because the process can take a while, be sure to be proactive and get started early to ensure a smoother path to becoming an in-network ABA provider.