Expert answers to your most pressing questions about insurance contracting, credentialing, and reimbursement in behavioral health
Whether you're new to behavioral health contracting or looking to optimize your existing agreements, our comprehensive FAQ covers the essential topics you need to understand. Click any category below to jump directly to relevant questions.
The credentialing process generally takes 90-120 days for most commercial insurance companies, though some can take up to 180 days. Medicare enrollment through PECOS typically takes 60-90 days, while Medicaid timelines vary by state. To minimize delays, ensure all documentation is complete and accurate before submission, maintain an updated CAQH ProView profile, and follow up regularly with payers.
CAQH ProView is a centralized database used by most major insurance companies to streamline provider credentialing. It stores your professional information, licenses, certifications, and practice details in one place. Over 1.5 million providers use CAQH, and maintaining an updated profile is essential as most commercial payers pull directly from this system. You must re-attest every 120 days to keep your information current.
Generally, you cannot bill as an in-network provider until credentialing is complete. However, some states and payers allow provisional credentialing or billing under supervision. For example, 11 out of 18 insurance companies in Colorado allow pre-licensed providers to bill under supervision. Always verify specific payer policies, as billing incorrectly can result in claim denials and recoupments.
Essential documents include: state license(s), DEA certificate (if applicable), malpractice insurance certificate, board certifications, NPI number, EIN/Tax ID verification (Form CP575 or 147C), educational transcripts/diplomas, work history for past 5 years, peer references, hospital privileges (if applicable), and disclosure statements. Keep all documents current and readily accessible to avoid delays.
This depends on your practice structure and goals. Individual credentialing gives you portability and independence but requires managing your own contracts. Group credentialing can streamline the process and may provide better negotiating power for rates, but ties you to the group's contracts. Many providers maintain both individual and group credentials for flexibility.
Credentialing is the verification process where insurers confirm your qualifications, licenses, and competency to provide care. Contracting is the business agreement that establishes you as an in-network provider, including reimbursement rates and terms. Credentialing must be completed before contracting, and both are required to become an in-network provider.
Most insurance companies require recredentialing every 2-3 years. Medicare requires revalidation every 5 years. CAQH ProView requires re-attestation every 120 days. Mark these dates in your calendar and begin the recredentialing process 120-150 days before expiration to avoid lapses in network status that could disrupt your revenue.
Common mistakes include: incomplete applications, expired documents, gaps in work history explanations, mismatched information across applications, missing required signatures, incorrect taxonomy codes, not following up on applications, letting CAQH attestation lapse, and using home addresses instead of practice locations. These errors can add months to the process.
Pro Tip: Start your credentialing process 6 months before you plan to see patients. This provides buffer time for delays and ensures continuous revenue flow.
Reimbursement rates are influenced by multiple factors: your location (urban vs rural), license type and specializations, years of experience, the specific CPT codes you bill, payer mix in your market, network adequacy needs, and your negotiation timing. Rates can vary by 50% or more between payers for the same service. Understanding these factors helps you identify opportunities for rate improvements.
Rates vary significantly across payers and regions. Commercial insurance typically reimburses 120-180% of Medicare rates, while Medicaid varies from 70-120% depending on your state. Within the same market, rates for a 60-minute therapy session (90837) might range from $80 to $200. Premium commercial payers often pay 2-3x more than Medicaid for the same service.
Yes, you can and should negotiate rates periodically. The best times are during contract renewal (usually annual), when adding new services or specializations, if you have long wait lists demonstrating high demand, after achieving new certifications, or when you can demonstrate superior outcomes. Many providers successfully negotiate 10-40% rate increases, especially when they can demonstrate value.
Medicare reimbursement rates for mental health therapy are decreasing by approximately 14.63% in 2025, with some urban areas seeing cuts exceeding 16%. This makes commercial and Medicaid contracting even more critical. Many states are offsetting these cuts by increasing Medicaid rates to 100-120% of Medicare levels, and commercial payers are facing pressure to maintain or increase rates to ensure network adequacy.
Start by reviewing Medicare's Physician Fee Schedule for baseline rates in your locality. Check your state Medicaid fee schedule for comparison. Network with other providers to understand market rates (while avoiding antitrust violations). Review your EOBs to calculate what percentage of Medicare each payer reimburses. Consider hiring a consultant who has access to aggregated rate data across payers.
This depends on your business strategy. Consider accepting lower rates if: the payer has high volume in your area, it helps fill empty appointment slots, you're building your practice, or it provides access to specific populations you want to serve. However, calculate whether the volume will offset lower rates and ensure the administrative burden doesn't outweigh the benefits.
Certain specializations typically receive premium rates: neuropsychological testing, autism spectrum disorder treatment, eating disorder treatment, intensive outpatient programs (IOP), partial hospitalization programs (PHP), trauma-focused therapies (EMDR, CPT), and medication management by psychiatrists. Documenting specialized training and certifications can justify 15-30% higher rates.
Value-based contracts tie reimbursement to quality metrics and outcomes rather than just fee-for-service. While still emerging in behavioral health, these contracts can offer bonuses for meeting targets like reduced readmissions, improved PHQ-9 scores, or high patient satisfaction. They require robust data tracking but can increase total reimbursement by 10-20% when performance targets are met.
Success Story: Our clients typically achieve 15-40% rate increases through strategic negotiation and demonstrating value to payers. The key is preparation and timing.
The main contract types include: Fee-for-Service (FFS) - traditional payment per service rendered; Capitation - fixed payment per member per month regardless of services; Case Rate - bundled payment for episode of care; Value-Based - payments tied to quality metrics and outcomes; and Shared Savings - bonuses for reducing total cost of care. Most behavioral health providers start with FFS contracts, though value-based arrangements are becoming more common.
UCPs are standardized requirements that must be included in all behavioral health contracts for specific services, regardless of the contracting parties. States like Colorado mandate UCPs to ensure minimum standards, fair obligations, and uniform access to care. These provisions cover areas like service delivery standards, documentation requirements, quality metrics, and payment terms.
Single Case Agreements (SCAs) are temporary contracts between out-of-network providers and insurance companies for specific patients. They're useful when: a patient needs specialized services not available in-network, maintaining continuity of care during transitions, or testing the waters before full contracting. SCAs typically offer higher rates than standard contracts but require negotiation for each case.
Critical non-rate terms include: timely filing limits (typically 90-365 days), prior authorization requirements, medical necessity criteria, termination clauses (aim for 90+ days notice), claims payment timeframes, audit and recoupment provisions, credentialing requirements for new providers, and network exclusivity restrictions. These terms can significantly impact your revenue and operations.
Insurance companies frequently send contract amendments, often with short response windows. Establish a system to: track all amendments and deadlines, review changes with legal counsel if needed, negotiate unfavorable terms before accepting, document your acceptance or rejection, and maintain organized records of all contract versions. Missing amendment deadlines can result in automatic acceptance of unfavorable terms.
Participating (PAR) providers agree to accept the insurance company's allowed amount as payment in full and cannot balance bill patients. Non-participating (non-PAR) providers can charge patients above the allowed amount but often receive lower reimbursement rates (typically 5-15% less) and face more administrative burden. Most behavioral health providers choose PAR status for better rates and patient access.
Yes, but follow the contract's termination provisions carefully. Most require 60-120 days written notice. Before terminating: attempt negotiation first, consider the impact on current patients, understand continuity of care obligations, verify you're not violating any network adequacy agreements, and plan patient transitions. Some contracts require you to continue treating existing patients for 90+ days post-termination.
Delegated credentialing allows larger organizations to credential providers on behalf of insurance companies. This can expedite the process from 120 days to 30-60 days. The delegated entity must meet NCQA standards and undergo regular audits. Individual providers joining organizations with delegated credentialing can often begin seeing patients sooner while maintaining their own credentials.
Important: Always have contracts reviewed by healthcare legal counsel before signing. Small details in contract language can have significant financial and operational impacts.
The complete timeline typically spans 4-6 months: Credentialing (90-120 days), Contract negotiation (30-60 days), System setup and testing (14-30 days), First claims submission (upon seeing patients), and First payment (30-45 days after claim submission). Plan for 6 months from initial application to steady revenue flow. Starting the process early is crucial for financial planning.
Major milestones include: 1) Application submission with complete documentation, 2) Primary source verification completion (30-45 days), 3) Credentialing committee review (monthly meetings), 4) Approval notification, 5) Contract offer received, 6) Rate negotiation (if applicable), 7) Contract execution, 8) Provider number assignment, 9) System loading and testing, 10) Go-live date confirmation. Track each milestone to identify and address delays quickly.
Prioritize based on: Market share in your area (target top 3-5 payers), Your target patient demographic, Reimbursement rates and terms, Administrative burden and requirements, Your capacity to handle different payers. Start with Medicare if eligible (most streamlined process), then major commercial payers (BCBS, UHC, Aetna), followed by regional payers and Medicaid MCOs.
Common delays include: Incomplete or incorrect applications, Expired or missing documents, Malpractice insurance gaps or issues, License verification problems, Disciplinary history requiring explanation, Background check discrepancies, Unresponsive references, Committee meeting schedules (often monthly), System or administrative backlogs, and Holiday periods. Proactive follow-up can prevent many delays.
Not necessarily. Consider these options while waiting: Accept self-pay patients with clear payment policies, Pursue single case agreements for specific patients, Work under supervision if allowed (check state laws), Join a group practice temporarily, Offer cash-pay packages at competitive rates, Focus on building your practice infrastructure, Network and market your services. Plan financially for the credentialing period.
Establish a consistent follow-up schedule: Week 1-2: Confirm receipt of application, Week 4: Check primary source verification status, Week 6-8: Inquire about committee review scheduling, Week 10-12: Request status update and timeline, After approval: Weekly follow-up on contract delivery. Document all communications and get updates in writing when possible. Persistence without being pushy is key.
Post-contract execution involves: Provider number assignment (1-2 weeks), System loading and verification (2-3 weeks), Provider directory updates (varies), Test claim submission recommended, Staff training on payer requirements, Verify fee schedules in your billing system, Confirm prior authorization processes, Update marketing materials and website, Notify referring providers of your network status. Don't assume you're ready to bill immediately after signing.
Managing multiple applications requires organization: Create a master tracking spreadsheet with deadlines, Set up a dedicated email folder for each payer, Use a secure cloud storage for documents, Maintain a credentialing calendar with key dates, Delegate where possible (credentialing services), Batch similar tasks (reference requests, document updates), Keep CAQH updated as your single source of truth, Consider professional credentialing software or services for 5+ applications.
Time-Saving Tip: Professional credentialing services can manage multiple applications simultaneously, reducing your timeline by 30-50% and ensuring nothing falls through the cracks.
Medicare enrollment requires: Active state license, NPI (Individual and/or Type 2), Malpractice insurance, Completion of CMS-855I (individuals) or CMS-855B (groups), PECOS enrollment, Background checks/fingerprinting in some states. Note that LPCs and LMFTs are not eligible for Medicare. The process typically takes 60-90 days. Psychiatrists, psychologists, and clinical social workers are eligible. Opt-in or opt-out decisions for Medicare participation affect your entire practice.
Medicaid varies significantly: Each state has unique enrollment processes, fee schedules, and covered services. Some states contract directly while others use MCOs exclusively. Rates range from 70-120% of Medicare. Many states are implementing significant rate increases (Iowa: 96.5% increase for SUD, Montana: $339M in increases). States may have different provider types eligible (some include LPCs, others don't). Always check state-specific requirements and consider working with local experts.
Priority depends on your market, but nationally dominant payers include: UnitedHealthcare (largest market share), Anthem/Elevance Health, Aetna/CVS Health, Cigna, Humana, and BCBS plans (state-specific). Research local market share data, as regional payers may dominate. Consider ease of contracting - Aetna and Cigna often have simpler processes. Evaluate both reimbursement rates and administrative burden. Some payers require facility accreditation or group practice structures.
TRICARE has unique requirements: Managed by regional contractors (Humana Military East, TriWest West), Requires separate certification even if you're with Humana/TriWest commercially, Often offers competitive rates (100-120% of Medicare), Serves military families with specific cultural competency needs, Has strict network adequacy requirements near military bases, Requires understanding of authorization processes for different TRICARE programs. Consider the military population density in your area before pursuing.
Medicare Advantage (MA) plans are managed by commercial insurers but serve Medicare beneficiaries. Key differences: Require separate contracting with each MA plan, Often have prior authorization requirements traditional Medicare doesn't, May offer better rates than traditional Medicare, Have network adequacy requirements that create opportunities, Growing rapidly (over 50% of Medicare beneficiaries). You must be Medicare-enrolled to contract with MA plans.
EAPs offer unique opportunities and challenges: Typically provide 3-8 sessions per year at no cost to employees, Lower reimbursement rates ($60-100 per session typically), High volume potential with large employers, Minimal billing complexity (no copays/deductibles), Often require 24-48 hour appointment availability, Can be a good source of referrals for ongoing treatment. Consider EAPs as supplemental rather than primary revenue sources.
Out-of-network strategies include: Verify patient benefits including deductibles and reimbursement rates, Provide detailed superbills for patient reimbursement, Consider courtesy billing (you bill insurance, patient pays you directly), Educate patients on their out-of-network benefits, Maintain clear financial policies and payment expectations, Use single case agreements for specific situations. Some practices thrive as out-of-network providers with proper patient education and support.
Narrow networks present both challenges and opportunities: Insurers limit network size to control costs, Higher reimbursement potential for included providers, Stricter credentialing and quality requirements, May require exclusive arrangements, Create access issues that regulators monitor, Network adequacy requirements can provide leverage. Position yourself as essential for network adequacy in underserved areas or specialties to improve negotiating power.
Market Insight: With public insurance now covering the majority of behavioral health services, understanding government payer requirements is essential for practice sustainability.
Network adequacy standards require insurers to maintain sufficient providers within reasonable time/distance of members. CMS added behavioral health specialties to Medicare Advantage requirements in 2024. Standards typically specify maximum drive times (30-60 minutes) and appointment wait times (10-14 days). These requirements create leverage for providers in underserved areas and can justify higher reimbursement rates when you help plans meet adequacy standards.
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires insurers to cover behavioral health services comparably to medical services. This means: Similar prior authorization requirements, Comparable reimbursement rate methodologies, Equal cost-sharing structures, Equivalent network adequacy standards. Parity violations can be reported to state insurance commissioners and create opportunities to challenge unfair contract terms.
Insurance contracts require comprehensive documentation: Treatment plans with measurable goals, Session notes meeting medical necessity criteria, Diagnosis supporting service level, Ongoing assessment of progress, Proper use of CPT and ICD-10 codes, Timely filing of claims (typically 90-365 days), Records retention (typically 7-10 years). Inadequate documentation is the leading cause of claim denials and recoupments during audits.
During audits, you must: Respond within specified timeframes (typically 30-45 days), Provide complete medical records requested, Maintain HIPAA compliance during record transmission, Cooperate with reasonable requests, Have representation rights (legal counsel advised), Appeal rights for adverse findings. Prepare by maintaining organized records, understanding your contracts, and having an audit response protocol. Regular internal audits can prevent problems.
Each state has unique licensing requirements affecting contracting: Separate licenses needed for each state of practice, Telehealth may require license in patient's state, Compact licenses emerging for some professions (Psychology - PSYPACT), Different scope of practice rules by state, Varying supervision requirements for provisional licenses. Plan for licensing costs and timelines when expanding across state lines.
When terminating contracts, you typically must: Provide 60-120 days notice to the insurer, Notify affected patients in writing, Continue treating current patients for 90+ days (varies by contract), Maintain the contracted rate during transition, Assist with care transitions, Document all patient notifications. Some states have specific continuity of care laws that override contract terms. Plan transitions carefully to avoid abandonment claims.
Key compliance areas include: False Claims Act (billing for services not rendered), Anti-Kickback Statute (paying for referrals), Stark Law (physician self-referral), Upcoding or unbundling services improperly, Waiving copays without financial hardship documentation, Balance billing in-network patients. Violations can result in exclusion from federal programs, significant fines, and criminal prosecution. Maintain strong compliance programs and seek legal guidance when uncertain.
If you employ or contract with other providers: Each provider needs individual credentialing, Group contracts may cover multiple providers, Delegated credentialing can expedite the process, Supervision arrangements must meet payer requirements, Incident-to billing has specific Medicare rules, Locum tenens arrangements need proper documentation. Track expiration dates and maintain current records for all providers. Non-compliance can result in payment recoupments.
Compliance Alert: Healthcare regulations change frequently. Always consult with healthcare attorneys and compliance experts to ensure your contracts and practices meet current requirements.
Access essential tools, databases, and authoritative sources to support your contracting and credentialing efforts. These resources provide current information on regulations, fee schedules, and industry standards.
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