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 applying to any MCO, you must be an approved Medicaid provider in your state. This involves:

• Applying through your state’s Medicaid enrollment portal
• 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.
• Providing your licenses, credentials, certifications, and tax info
• Completing a background check (varies by state)

You cannot apply to an MCO until this step is complete.

Each state contracts with multiple MCOs to administer Medicaid benefits. Find out:

• Which MCOs your potential clients are enrolled with
• Which plans cover ABA services in your region

Each MCO has its own credentialing process, usually through an online portal or provider network management system. You’ll typically need to provide:

• Your NPI number
• CAQH provider profile (must be up to date and attested). 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. 
• Proof of liability/malpractice insurance
• W-9 form and business documentation
• Staff credentials (BCBAs, RBTs, etc.)

You must submit separate applications for each MCO.

MCOs will review your application and may:

• Verify licenses, references, and experience
• Request additional documentation
• Schedule a site visit or phone interview

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

Once approved, you’ll receive a provider agreement. You’ll need to:

• Sign and return the contract
• Set up your billing portal
• Learn the MCO’s billing codes, documentation rules, and prior auth process

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.