Behavioral Health Credentialing: Requirements, Process, and Best Practices

What Makes Behavioral Health Credentialing Different?

Behavioral health credentialing follows the same general principles as medical credentialing, but with important differences that can trip up providers who aren't prepared. The most significant difference is the behavioral health carve-out structure used by many major insurance companies.

In a carve-out arrangement, the insurance company contracts with a separate behavioral health organization to manage mental health and substance abuse benefits. This means behavioral health providers often credential through a different entity than medical providers, even when they're joining the same insurance plan.

Understanding Behavioral Health Carve-Outs

Here's how major payers structure their behavioral health credentialing:

UnitedHealthcare / Optum

UnitedHealthcare manages behavioral health through Optum Behavioral Health. Behavioral health providers typically credential through Optum's provider portal rather than through UnitedHealthcare directly. The process uses CAQH ProView data but has its own application requirements.

Cigna / Evernorth

Cigna's behavioral health benefits are managed by Evernorth Behavioral Health (formerly Cigna Behavioral Health). Credentialing applications go through Evernorth's provider portal. Evernorth has specific documentation requirements that differ from Cigna's medical credentialing.

Blue Cross Blue Shield / Carelon

Many BCBS plans contract with Carelon Behavioral Health (formerly Beacon Health Options) to manage behavioral health. However, this varies by state, as BCBS operates as independent companies in different regions. Some BCBS plans handle behavioral health credentialing in-house.

Aetna

Aetna generally handles behavioral health credentialing through its own credentialing department rather than using a carve-out. This can simplify the process, but Aetna has specific requirements for behavioral health providers that differ from their medical provider credentialing.

Humana

Humana manages behavioral health credentialing internally for most plans. Their process is relatively straightforward and relies heavily on CAQH ProView data.

Behavioral Health Credentialing Requirements

The specific requirements vary by payer, but behavioral health providers generally need:

• An active, independent-level behavioral health license (LCSW, LPC, LMFT, PhD/PsyD, MD, PMHNP, etc.)
• NPI number (Type 1 for individual providers, Type 2 for organizations)
• Professional liability insurance meeting payer minimums
• Completed CAQH ProView profile
• Clean background: no sanctions, exclusions, or malpractice history
• Board certification (required by some payers for psychiatrists and psychologists)
• Minimum experience requirements (some payers require 1-2 years post-licensure)

License Types and Payer Acceptance

Not every behavioral health license is accepted by every payer. Here's a general guide:

• Psychiatrists (MD/DO): Accepted by all payers.
• PMHNPs: Accepted by most payers. Growing demand has opened many previously restricted panels.
• Psychologists (PhD/PsyD): Accepted by all payers.
• LCSWs: Accepted by virtually all payers. The most universally credentialed therapy license.
• LPCs/LMHCs/LPCCs: Accepted by most major payers, though some older contracts may have restrictions.
• LMFTs: Accepted by most commercial payers. Medicare acceptance varies by state.
• LADCs/CASACs: Acceptance varies widely. More commonly credentialed through Medicaid and substance abuse carve-outs.
• Provisionally licensed providers: Generally not eligible for insurance credentialing with commercial payers.

The Behavioral Health Credentialing Process

1. Identify target payers: Research which payers have the most members in your service area and which offer the best reimbursement rates for behavioral health.
2. Determine the credentialing entity: For each payer, identify whether behavioral health credentialing goes through the main company or a carve-out organization.
3. Complete CAQH ProView: Ensure your profile is 100% complete with all behavioral health-specific information.
4. Submit applications: Apply through the correct portal for each payer's behavioral health network.
5. Track and follow up: Maintain a tracking system for each application with regular follow-up calls.
6. Review contracts: When approved, carefully review your behavioral health fee schedule.

Behavioral Health CPT Codes and Reimbursement

Understanding which CPT codes drive your revenue is essential for evaluating contract offers:

• 90791: Psychiatric diagnostic evaluation (intake). Typically your highest-reimbursed code.
• 90792: Psychiatric diagnostic evaluation with medical services. For prescribers.
• 90834: Individual psychotherapy, 45 minutes. High volume code for therapists.
• 90837: Individual psychotherapy, 60 minutes. Higher reimbursement per session.
• 90847: Family psychotherapy with patient. Important for family therapists.
• 90853: Group psychotherapy. Lower per-patient reimbursement but higher volume potential.
• 99213/99214: E&M codes used by psychiatrists and PMHNPs for medication management.

When reviewing a contract, focus on the rates for the codes you bill most frequently. A small rate improvement on a high-volume code has a large impact on annual revenue.

Best Practices for Behavioral Health Credentialing

• Apply to multiple payers simultaneously to minimize total wait time.
• Keep your CAQH profile current and re-attest every 120 days.
• Build relationships with payer provider relations representatives.
• Document every interaction with payers: dates, names, reference numbers.
• Don't accept initial rate offers without negotiation.
• Plan for re-credentialing, which is required every 2-3 years by most payers.
• Consider working with a behavioral health contracting specialist who knows the carve-out landscape.

Get Expert Help with Behavioral Health Credentialing

Behavioral Health Contracting specializes exclusively in behavioral health credentialing and payer contracting. We navigate the carve-out landscape daily and know exactly how to get behavioral health providers credentialed efficiently with the best possible rates.

Contact us for a free consultation to discuss your credentialing needs.