The administrative challenges Massachusetts BHPs encounter when participating in insurance networks are increasing. If you are an LMHC, LICSW, psychiatrist, psychologist, counselor, therapist, substance use disorder provider, or behavioral health facility, it’s important to be appropriately credentialed by insurance payers before you can confidently be an in-network provider and bill for covered services.

Credentialing is more than completing an insurance application. Before a provider is added to a health plan’s network, the plan checks the provider’s professional licenses, education, work history, malpractice coverage, NPI information, practice locations, ownership information, CAQH data, and other records. There are additional licensing, accreditation, staffing, and program documentation requirements for behavioral health facilities.

The negative financial effects of delayed credentialing can be substantial. However, if a clinician has patients in treatment and payer enrollment is pending, claims submitted prior to the effective date of payer approval may be denied, processed out of network, or require further follow-up. These delays can impact revenue and cash flow for behavioral health organizations that add clinicians en masse in a short period of time.

VerifiMed offers credentialing services for substance use disorder programs, behavioral health organizations, group practices, and individual practitioners in Massachusetts. We aim to streamline the payer enrollment process, facilitate paperwork organization, keep CAQH data up-to-date, follow up with insurance providers, and support providers in navigating the credentialing process efficiently.

But What Is Behavioral Health Credentialing, and Why Is It Important?

Behavioral health credentialing is a process used by insurance companies to determine whether an insurance company participant holds the proper professional standing, licenses, experience, and qualifications to be a part of the insurance company.

Credentialing should not be confused with professional licensure. A clinician who is licensed in Massachusetts has a license to practice within the scope of his or her license. Insurance credentialing is an independent process. A therapist may be licensed in Massachusetts but must go through credentialing and contracting with an insurance company in order to be an in-network provider for that insurance company.

As part of the credentialing process, insurance companies frequently check the provider’s National Provider Identifier, Massachusetts license, education, postgraduate training, work history, malpractice insurance, practice location, professional referral or affiliation (where applicable), sanctions history, and information in CAQH.

The process is also relevant to existing practices. Credentialing updates may be warranted whenever a behavioral health organization hires a new clinician, a new location is established, new payers are added, ownership data is updated, or services are expanded.

Accurate credentialing also leads to smoother medical billing. Otherwise valid claims may be rejected if the information in the claim does not match the information in the insurance company’s records, including information from the billing NPI, rendering provider information, taxonomy code, payer effective date, group affiliation, or service location.

Having Knowledge of the Behavioral Health Credentialing Challenges in Massachusetts

Massachusetts’ behavioral health landscape is complex due to the fact that various professions and programs are overseen by distinct agencies and licensing boards.

In the case of an LMHC, the licensing process is not the same as the licensing process for an LICSW. Physicians are psychiatrists and are regulated by a different regulatory board than counselors and social workers. Some residential programs and facilities may be licensed by the Massachusetts Department of Mental Health, and others may be licensed by BSAS under the Department of Substance Addiction Services.

Add another layer of complexity — payers. MassHealth, Blue Cross/Blue Shield of Massachusetts, Medicare, Carelon Behavioral Health, and commercial insurance companies have their own enrollment and credentialing procedures. Some use CAQH extensively, while others use independent provider applications, organization documents, or facility forms.

The difficulty isn’t getting one document. It’s ensuring consistency of information throughout various systems.

The legal name, Tax ID, NPI, CAQH profile, payer application, service address, billing address, and taxonomy codes of a practice should be consistent. The process of credentialing can be lengthened, and requests for clarification can be issued if there are even minor inconsistencies.

For regular practices, credentialing should then be an integrated administrative process, not a chore done when a provider starts working with patients.

Who Should Consider Behavioral Health Credentialing?

Massachusetts behavioral health credentialing consists of two general types of credentialing: credentialing of individual clinicians and credentialing of organizations or facilities.

Individual credentialing is used for professionals who work in the health care field and are licensed to do so. This can include psychiatrists, psychologists, LICSWs, LMHCs, LMFTs, psychiatric nurse practitioners, and other qualified behavioral health practitioners, depending on the scope of practice and/or payer rules.

If an organization wants to be recognized by an insurance payer, then it is called facility credentialing. Depending on services and licensing, behavioral health clinics, substance use disorder treatment programs, residential programs, psychiatric facilities, community behavioral health organizations, intensive outpatient programs, and other institutional providers could be in this category.

It is the quantity and quality of documentation that differs.

If a single clinician is added to an existing group, he/she may need to be personally credentialed and added to the group’s payer contract. This step of affiliation is especially critical because even if the clinician is independently credentialed, it does not guarantee that the clinician is properly affiliated with the billing group.

The Regulatory Bodies of Massachusetts Behavioral Health Organizations

Depending on the type of services and profession, Massachusetts behavioral health providers can have interactions with multiple state regulatory agencies.

Board of Registration of Allied Mental Health and Human Services Professions

Mental Health Counseling and Marriage and Family Therapy are among the behavioral health professions regulated by the Massachusetts Board of Registration of Allied Mental Health and Human Services Professions.

Before commercial payers complete credentialing, they mostly require an LMHC or LMFT to be currently licensed and in good standing in Massachusetts. Providers must also ensure that their payer applications show the same name and license information as shown in the state’s licensing record.

The Board of Registration of Social Workers Is Also the Board of Registration of Mental Health Therapists

Massachusetts social workers are regulated independently by the Board of Registration of Social Workers.

This is relevant for credentialing purposes, as LICSWs are not classed as providers regulated by the Allied Mental Health board. Massachusetts has a number of levels of social work licensure, and sometimes eligibility for licensure is determined by the insurance company the individual is paying for.

It is typical for behavioral health networks to credential LCSWs, as they are usually able to deliver covered psychotherapy and other behavioral health services within their scope of practice independently.

Massachusetts Department of Mental Health (Mass DMH)

The Massachusetts Department of Mental Health (DMH) is responsible for certain parts of the state’s public mental health system and for licensing some mental health facilities and programs.

A behavioral health provider will need a DMH license before it can initiate payer facility credentialing, depending on the organization’s structure and services. This is particularly important for organizations operating regulated residential or psychiatric programs.

Credentialing is an important first step, as a payer can request access to the applicable state license.

Bureau of Substance Addiction Services

The Massachusetts Department of Public Health (DPH) has a Bureau of Substance Addiction Services (BSAS).

BSAS manages the state’s system of substance addiction treatment and regulates a variety of substance use disorder services and programs. Before enrolling an organization with insurance payers for treatment for SUDs, the organization should know what licensing is required for the facility.

These providers might need to provide documentation about program licensure, treatment services, staff, medical supervision, and other operational aspects for use in the credentialing process.

The Massachusetts Department of Public Health

DPH has a wider mandate as a health regulator across Massachusetts.

DPH has several behavioral health licensing and professional regulatory components, and BSAS is a part of DPH. Massachusetts does not have one single behavioral health license, so providers should determine which license to use for their specific provider type and program.

CAQH ProView Is Designed to Assist in Behavioral Health Credentialing

As one of the most critical systems utilized in the commercial insurance credentialing process, CAQH is a focal point.

Many behavioral health providers are still familiar with the system as CAQH ProView, and CAQH has continued modernizing and updating its provider data platforms. The essence of the process, whether it is a naming change or not, is the same: providers store professional information in one place and give health plans permission to access that information during the credentialing process.

The components of a behavioral health provider’s CAQH profile typically include licensure, education, training, work history, addresses, malpractice insurance, NPI information, disclosure questions, and supporting documentation.

A frequent error in credentialing is not considering CAQH as a single application, but rather as a recurring one.

Provider information needs to remain up-to-date. The CAQH profile should be updated if there is a change in the clinician’s malpractice policy, a change in office location, a change in license, or a change in professional information. Also, providers must attest to the information periodically to allow insurance companies to access the information.

Another frequent problem is that there is no consistency between CAQH and the payer’s applications. The payer may refuse to process the application until the discrepancy between the two addresses is corrected if there is a difference between the practice address entered in CAQH and the address given to the insurance company.

VerifiMed can assist behavioral health practices in ensuring accurate CAQH profiles and synchronizing CAQH information with payer enrollment documentation.

Facility-Level Behavioral Health Credentialing Requirements

Generally, the credentialing of a facility or organization is more complex and is more likely to involve a greater amount of paperwork than the credentialing of an individual therapist or counselor.

An insurance company that is considering adding a behavioral health facility to its network wants to ensure that the facility is properly established, licensed, insured, staffed, and authorized to provide the services submitted for network coverage.

Facility credentialing can include documentation such as the organizational NPI, federal Tax ID, W-9, facility ownership information, applicable Massachusetts facility license, professional and general liability insurance, staffing information, provider rosters, clinical program descriptions, service locations, operating hours, and accreditation documentation, if applicable.

The behavioral health facility also might be required to provide information concerning its clinical director, medical director, supervision, treatment programs, emergency protocols, or record of government inspections or surveys.

CARF and Joint Commission Accreditation

Behavioral health care providers often are made aware of accreditation from either CARF or The Joint Commission, but these accreditations are not required for all behavioral health facilities in Massachusetts.

It varies by the type of facility, services rendered, state licensing requirements, and the credentialing requirements of the payer.

CARF, The Joint Commission, and other recognized accrediting organizations are accepted by some insurance networks. In some cases, a government survey or regulatory review in a non-accredited facility may be accepted as an alternative to accreditation.

This is why it’s important for behavioral health organizations to verify the exact needs of a payer before they pay for or seek accreditation just for credentialing.

Behavioral health organizations often require a more customized credentialing approach based on provider type, services, licensing, and payer requirements. VerifiMed also supports providers in other specialties and markets, including Chiropractic Credentialing Texas, helping practices manage payer enrollment and credentialing requirements more efficiently.

Chucking It With the Big Guys in Massachusetts

Massachusetts behavioral health providers might need to sign up with multiple insurance plans based on their patient population.

MassHealth Credentialing

MassHealth is Massachusetts’ Medicaid program and Children’s Health Insurance Program and plays a significant role in payment to many behavioral health practices.

To participate as MassHealth providers, providers must have the necessary enrollments completed. Requirements vary by provider type, practice structure, service category, and individual or organizational enrollment.

Validating NPIs, licensing data, service locations, tax data, ownership information, controlling interest information, and provider affiliations may be part of the MassHealth enrollment process.

It is also important to be aware that simply enrolling in MassHealth does not mean that all MassHealth managed care and behavioral health network enrollments have been finalized.

Massachusetts Behavioral Health Partnership and Carelon Behavioral Health

Massachusetts Behavioral Health Partnership (MBHP) is a part of Carelon Behavioral Health.

Carelon oversees processes in the behavioral health network on behalf of a variety of individual practitioners, groups, and facilities. The processes to credential may vary from the perspective of a single clinician, group practice, or behavioral health facility.

Applications for individual providers may only include professional credentials and information from CAQH, and facility applications may include a significant amount of documentation required for licensing, insurance, service programs, staffing, organizational NPI information, accreditation information, and survey information.

Selecting the right type of application from the start can avoid unnecessary credentialing delays.

The Standard Is Set by Blue Cross Blue Shield of Massachusetts

Another significant payer of behavioral health services in Massachusetts is Blue Cross Blue Shield of Massachusetts (BCBSMA).

Most credentialing providers will rely on CAQH as a key component of the credentialing process. Institutional and organizational providers have their own application process, and supporting facility documentation may need to be submitted directly to the institutional and organizational provider.

In practices with multiple clinicians, it’s crucial that the provider is approved as an individual provider and becomes affiliated with the appropriate practice location and billing entity.

These are the phases VerifiMed monitors to help the practice know when a clinician is ready to bill as an in-network provider.

Medicare Behavioral Health Enrollment

In recent years, Medicare has begun to cover some behavioral health providers, making Medicare enrollment more relevant to therapists and counseling practices.

Medicare’s electronic provider enrollment system, PECOS, may require the enrollment of eligible behavioral health professionals.

Enrollment may include documents such as the clinician’s NPI, professional license, clinician enrollment record, group information, reassignment of Medicare benefits, practice locations, banking information, and more.

Careful coordination of the billing system with Medicare credentialing is required for behavioral health groups. Sometimes the individual needs to be enrolled in Medicare and request reassignment to the group before claims can be submitted properly.

Commercial Insurance Carriers

Commercial payers like Aetna, Cigna/Evernorth, UnitedHealthcare-related behavioral health networks, Harvard Pilgrim Health Care, Tufts Health Plan, and others also might be interested in participating with Massachusetts behavioral health practices.

Requirements for credentials and networks may differ for various specialties and geographic locations. Some plans might temporarily remove some panels of providers, whereas others may actively seek certain behavioral health specialties.

That is why the process of credentialing should be the responsibility of each individual payer and not a blanket program or enrollment strategy.

Typical Reasons for Delays and Denial in the Common Credentialing Process

When an insurance company finds inconsistencies across multiple data sources or can’t verify information, credentialing delays can occur.

One of the biggest issues is an incomplete CAQH profile. A provider may think a profile is complete even if the malpractice policy has expired, the attestation is late, the provider’s employment record is missing some parts, or the provider has not been authorized by the payer to access the information.

Discrepancies in NPI and taxes can also lead to delays. If a group application is filed under a Type 2 NPI, but the legal entity name on the W-9 or payer file is different, for instance, then further verification may be needed.

Another common cause of issues is practice addresses. The address provided in CAQH, NPPES, the payer application, and the practice’s tax records should be compared to see if they are the same.

Applications for facility credentialing may be delayed if the documents needed for a license application, insurance certificates, proof of ownership, provider lists, accreditation documents, or program information are missing.

Even though an application is deemed to be operating correctly, it may still be delayed because the provider takes too long to respond to a request from a payer for more information. Some credentialing departments may only allow a few days to respond, and an application could be denied if the necessary forms are not received.

Hence, follow-ups are as crucial as the initial submission.

Credentialing Timelines in Massachusetts

No single credentialing time frame applies to all behavioral health payers in Massachusetts.

Some providers may take even longer, while others may take considerably less; in total, many providers should expect this entire process to take about 60 to 120 days for planning purposes.

The timeline is influenced by several factors: type of provider, workload of the payers, network availability, documentation completeness, primary-source verification, contracting requirements, state licensure issues, and the presence of facility review.

Also, keep in mind that once a provider is credentialed, it doesn’t necessarily mean that they can start billing as an in-network provider right away.

Typically, the process progresses in a few steps:

App. Subm. → Cred. Review → Approval → Contracting → Network Effective Date

The payer’s official effective date needs to be verified by the behavioral health provider prior to issuing a claim as in-network.

Ideally, practices should start credentialing prior to the provider’s start date. Delays of just a few weeks from the onset of employment can mean weeks or months in which the clinician is not able to bill some insurance plans.

We Provide Behavioral Health Credentialing Services in the State of Massachusetts

VerifiMed offers full behavioral health credentialing services to individual clinicians, behavioral health groups, mental health practices, substance use disorder programs, and facilities in Massachusetts.

The first step in our credentialing process is to examine the provider’s professional and practice information. We identify the insurance networks the practice wishes to join, the pathway to apply for membership in each network, and organize the documentation needed for each insurance network.

CAQH Setup and Maintenance

VerifiMed supports providers in creating and updating CAQH profiles, uploading documents, providing practice information, malpractice coverage, and ongoing maintenance of their profiles.

Additionally, we review CAQH data with payer applications to minimize inconsistencies that can result in further requests for information.

You Can Now Enroll and Credential Payers

We support commercial payers in credentialing and network enrollment of behavioral health providers.

Instead of just sending an application, we follow the credentialing process, follow up with payers, receive requests for documentation and follow-up, and confirm participation and effective dates.

To Enroll in MassHealth and Medicare

Providers needing assistance with MassHealth and Medicare administrative processes can get help enrolling with government payers.

This can include provider reassignment, practice-location updates, provider enrollment coordination, and enrollment assistance for Medicare providers.

We assist MassHealth in arranging enrollment information and documentation based on the applicable enrollment category.

Facility Credentialing

In general, behavioral healthcare facilities need a more individualized credentialing process.

VerifiMed can help you prepare and organize all of the following: facility licensing documents, organizational NPI information, Tax ID records, insurance certificates, ownership information, staffing rosters, program descriptions, accreditation documentation, and payer-specific forms.

Group Affiliations and Provider Additions

Individual credentialing may not be sufficient when a behavioral health practice adds a new therapist/clinician.

The provider may also have to be appropriately connected with the group’s Tax ID, Type 2 NPI, location, or payer contract.

VerifiMed can assist in facilitating these affiliations so that the provider is properly linked with the billing entity.

Ongoing Maintenance and Recredentialing

Insurance credentialing continues after approval.

Payers recredential providers periodically and may require updated malpractice insurance, professional history, practice information, and licenses. Providers are also required to report significant changes, such as a change of location, change of owners, change of name, or termination of clinicians.

VerifiMed assists practices with these changes and with keeping payer records up to date.

Why Opt for VerifiMed Behavioral Health Credentialing?

Behavioral health professionals should be able to spend more time on patient care and less time checking payer portals, filling out repetitive applications, and making follow-up calls.

VerifiMed is a blend of medical credentialing and medical billing/revenue cycle expertise. This is critical, as payment can be directly influenced by payer enrollment.

We know that sometimes a provider’s NPI organization, payer association, effective date, taxonomy, or service location is incorrect and can eventually lead to a billing problem. We, therefore, take into account not only the approval but also the provider’s representation on claims.

Partnering with individual clinicians and organizations, our approach can be modified to the needs of an independent therapist, expanding behavioral health group, SUD treatment provider, or larger behavioral health facility.

We also concentrate on follow-up. Once a program has been submitted, credentialing should not stop. Requests for payment, credentialing decisions, contracting, affiliations, and effective dates need to be tracked until the enrollment process is closed.

Enhance Your Behavioral Health Practice With VerifiMed

As a practice grows, hires clinicians, opens additional locations, or joins other insurance networks, managing credentialing for behavioral health can become more complex, especially in Massachusetts.

VerifiMed streamlines and enhances the credentialing process for LMHCs, LICSWs, therapists, counselors, psychologists, psychiatrists, behavioral health groups, substance use disorder programs, and behavioral health facilities, while providing greater organization and visibility.

Our team assists with the CAQH management process, commercial payer applications, MassHealth enrollment, Medicare credentialing, facility enrollment and recredentialing, provider affiliations, documentation support, and payer follow-up.

Reimbursement delays, avoidable enrollment issues, and a better foundation for your behavioral health revenue cycle are all possible benefits of proper credentialing.

Call VerifiMed today to find out more about our behavioral health credentialing services in Massachusetts and to receive additional assistance in the process of payer enrollment for your behavioral health practice or facility.