With the ongoing demand in the Applied Behavior Analysis (ABA) field comes tremendous growth of new ABA organizations. Starting up an ABA practice can be rewarding, albeit a daunting process with many steps along the way. One of the first steps a new organization must take is getting credentialed with payors. Read on to learn about the processes for getting credentialed as a provider of ABA therapy services.
Understanding the Credentialing Terminology
Before we dive into the process of getting credentialed as a provider of ABA services, it’s essential to understand the terms associated with the process.
Credentialing versus Contracting
Credentialing and contracting are two distinct concepts that are often incorrectly used interchangeably. Credentialing refers to an insurance payor verifying that someone is a medical provider qualified to provide the service. The payor considers the provider’s background, education, certifications, and licenses in determining qualification. Conversely, contracting refers to the process of formalizing agreements between the payor and the provider. Contracting involves getting approved to work with a particular payor, either in or out-of-network. Contracting consists of completing an application directly with the payor and establishing legally binding agreements upon application approval, including agreeing upon paid rates for services.
Typically payors begin the contracting process with a provider, and as they work through those details, they will finalize the initial credentialing during the contracting. Thus, the contract application comes first in the process.
It is important to note that being contracted and credentialed with a particular payor does not mean you are pre-authorized to provide services for any given client. You will still need to follow each payor’s established process for gaining authorization for individual clients.
Individual versus Group Contracts
Group contracts involve a company becoming in-network with the insurance company, whereas individual contracts are created for each individual provider. With group contracts, each provider working for the organization must be credentialed and added under the company’s name. When a provider leaves the practice, they are removed from the contract with the payor.
Process for Credentialing with Payors
- Prepare the necessary information and documentation
You’ll need several items to begin the credentialing process. While each payor has different requirements, the following information is generally required as part of the credentialing process:
- Applicant’s personal demographic information, including work history, educational information, licensing, and certification
- Organization’s information, including address, email, phone and fax number
- Taxpayer Identification Number (TIN)
- National Provider Identifier (NPI)
- Liability and malpractice insurance documentation
- CAQH Provider ID Number (Note: If you are not using CAQH, you may need to provide additional documentation)
- Practice specialties, appointment availability, and languages spoken
- Review each payor’s credentialing process
There is no universal process for credentialing with payors. Each payor may have a different application process. Review the steps required for each payor you are interested in credentialing with. You can typically find the instructions on each payor’s website. Navigate to the website and locate the “provider” or “becoming a provider” section.Carefully consider whether you want to work with each provider before starting the process. Consider whether your target market is likely to encompass clients with that insurance provider, what the payor rates might be (if publicly available), and any potential challenges that may be involved in the process.
- Follow the payor’s directions for completing an application
Follow the payor’s directions for completing the application. Collect and submit any required documentation.
- Wait and follow up as needed
Credentialing can take time to complete. You should not begin services with clients while waiting on credentialing to complete unless you have a single case agreement in effect or you are providing private pay services.
The credentialing and contracting process can take some time, especially for new providers and startup organizations. Every payor has a different process, so timing can vary. Some payors may process things quicker. However, you should expect the initial process to take up to 6 months. Credentialing additional providers can take anywhere from 1-4 months. Therefore it is important to plan ahead and begin the credentialing process early.
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