On July 30 this year, Medicaid marked its 60th anniversary alongside Medicare. These two healthcare coverage programs were signed into law by President Lyndon B. Johnson. Since then, millions of low-income families, seniors, and disabled citizens have benefited from subsidized healthcare.
The Medicaid program is run within federal guidelines. However, each state is allowed considerable flexibility for its management. That’s why, just like eligibility and covered benefits vary across states, the Medicaid provider credentialing process varies, too, making it difficult for applicants to follow through. But what most fail to understand is that once the Medicaid credentialing process is broken down into digestible steps, the core is the same. And once you master the core, slight state-specific variations are easy to overcome.
So, are you ready to get credentialed and join Medicaid’s 70.8 million beneficiary-wide network?
A Step-by-Step Guide to Medicaid Credentialing Application
If you are a healthcare provider and are interested in credentialing with Medicaid, you must follow these steps to file a successful Medicaid credentialing application.
Step 1: Confirm Your Eligibility
First and foremost, you must verify if you are eligible to become a Medicaid-credentialed and approved provider in your community. For this, you must visit your state’s Medicaid program center or online resources and check if you meet the eligibility criteria.
To put it simply, you must be one of these:
- Physician (MD or DO)
- Dentist
- Pharmacist
- Nurse practitioner
- Physician assistant
- Therapist (physical, occupational, speech-language)
- Social worker
- Mental health counselor
- Clinic
- Hospital
- Home health agency
- Durable medical equipment (DME) supplier
- Laboratory
Note that even if you are enrolled in Medicare, you must separately file a Medicaid credentialing application and enroll in the network before rendering services to beneficiaries and billing Medicaid for them.
Step 2: Complete Your Medicaid Credentialing Application
Now comes the hard part. Filling out the correct Medicaid credentialing application form (the one specific to your state) and ensuring that all the details provided are complete and accurate is easier said than done. The process is time-consuming, requires attention to detail, and may have additional steps if your state’s Medicaid requires them.
For clarity, let’s take the example of Texas Medicaid, which is managed by Texas Medicaid & Healthcare Partnership (TMHP). It requires providers to submit an online/electronic application on the Provider Enrollment and Management System (PEMS) for smooth credentialing and enrollment.
Step 3: Submit the Required Documents
After logging in to the PEMS (for providers credentialing with Medicaid Texas), accessing the new credentialing tab, and proceeding through your Medicaid provider credentialing application, you must attach all the supporting documentation, such as educational certificates, licenses, and a curriculum vitae (CV), to back up your mentioned credentials.
The PEMS interface will systematically list down the documents you are required to attach, including the acceptable file formats, so be sure to submit them accordingly.
Step 4: Check Your Medicaid Credentialing Application Status
Once your application has been submitted, a specialist will review it. In case any deficiencies are detected, you will be contacted through the portal to correct them. Note that this review and waiting period can be 4 to 12 weeks long (30 to 90 days), during which you may get a request for a site visit and require approvals from state agencies, such as Texas Health and Human Services (HHSC). If additional documents, clarifications, or information are requested, provide them as soon as possible.
It is also recommended that you monitor your Medicaid credentialing application status regularly to ensure everything is on track and being processed promptly.
Step 5: Enroll and Sign the Contract
Your state’s Medicaid will send you a notification letter once it has approved your credentialing request and is ready to enroll you in the network. This will include your unique 6-digit Medicaid Provider Number (MPN).
After this, you will be sent a Medicaid Provider Agreement. Signing this contract will finalize your participation in the Medicaid network. Now, you can render healthcare services to Medicaid members and bill the state for incurred expenses.
Note that a mandatory orientation session and training may follow contract signing.
Medicaid Provider Credentialing Requirements
But what credentials must you have and provide to submit a successful Medicaid credentialing application? Unsure? Don’t worry. In this section, we will discuss the Medicaid credentialing requirements so you can prepare the paperwork in advance and fast-track the application process.
- Valid license for practicing in that state
- Board certifications
- Certifications of education and training
- Professional liability insurance
- National Provider Identifier (NPI) number
- Drug Enforcement Administration (DEA) number
- Tax ID Number (TIN)
- Social Security Number (SSN)
- Work history
- Malpractice insurance
- References
- Fingerprints
- Application fee (may vary by state). For example, $730 for New York Medicaid.
Note that while the basic requirements for Medicaid credentialing remain the same in all 50 states, some states may require additional information and documents, especially from high-risk category providers.
Challenges in Getting Credentialed with Medicaid
As we have stated before, getting credentialed with Medicaid is not an easy feat. You may encounter several hurdles in your months-long journey. From varying eligibility criteria to missing certifications and unresponsive references to late submissions, several factors can derail your Medicaid provider credentialing. That’s why you should familiarize yourself with the common challenges and devise strategies to navigate them skillfully.
Changing Medicaid Credentialing Requirements Across States
Be it Medi-Cal (California Medicaid) in the West or MassHealth (Massachusetts Medicaid) in the East, credentialing requirements vary slightly across the 50 states. This is because each state implements its own laws to manage healthcare funding, regulate the industry, and keep a check and balance on providers operating in its jurisdiction. You will notice this in terms of the online portal used for application submissions, professional liability insurance amounts, the requirement to or not to credential separately with Managed Care Organizations (MCOs) and Dental Maintenance Organizations (DMOs), and more.
These changing Medicaid credentialing requirements can confuse applicants, especially providers that operate in multiple states, leading to erroneous application submissions.
Understanding the Types of Medicaid Credentialing
Before you start filling out the Medicaid credentialing application form, you must determine what type of credentialing you are aiming for. Are you getting credentialed with Medicaid for the very first time (initial credentialing), or are you already an enrolled provider but going through re-credentialing (after 3-5 years) to ensure that you continue to meet Medicaid’s standards? Or are you midway through the process and rendering care (provisional credentialing) while your full application is being processed? Your particular situation will decide the type of Medicaid credentialing you apply for.
The challenge? Providers often don’t even know whether they can apply for provisional credentialing with Medicaid and unnecessarily delay offering services to their patients.
Outdated Information and Delayed Renewal
Some providers get so preoccupied with their clinical duties that they forget to update their credentials. They end up submitting old CVs, expired licences, and former addresses, which leads to credentialing delays or rejections.
Moreover, often providers sit on their re-credentialing applications for months. They either submit their applications at the last minute and rush through the process, which results in several mistakes, or create drafts and leave them idle until they are automatically deleted after 180 days.
Communication Deadlocks and Long Wait Times
Another major challenge that providers face during Medicaid credentialing is communication gaps. While some states have robust Medicaid programs with frequently updated websites, responsive customer service, and efficient outreach, other states keep providers in limbo, where they desperately search for correct information.
Moreover, long review periods with extensive background checks add to the stress, bringing patient care and revenue cycles to a standstill.
Best Practices for Medicaid Insurance Credentialing
Want to improve your Medicaid provider credentialing success rate? Follow these best practices and become a part of the statewide network.
Research and Plan Ahead
Don’t take a shot in the dark. Remember that you are trying to get credentialed and eventually enrolled in a network that will give you access to millions of patients. Not only will it increase your credibility, but it will also unlock a steady revenue stream. So, instead of taking a chance with your Medicaid credentialing application, complete the necessary groundwork, thoroughly research your state’s Medicaid credentialing requirements, and clear all the doubts beforehand.
Stay Organized
Our next advice is to organize your paperwork in advance. Keep separate folders for your educational and work documents, board certificates, and licenses, and arrange everything in chronological order. Leverage technology to store everything on a secure Cloud database so it is accessible to you and concerned parties remotely.
State the Truth
Do not bend the truth when you are completing your Medicaid credentialing application. If there were instances of malpractice in the past, mention them and give proper reasoning. Similarly, if your license was revoked or the employment contract was terminated, clearly explain your side of the story. Reviewers will verify your information anyway, so it is better that they hear it from you than from other sources.
Double Check All the Information
Do not submit your application in haste. Go through every page of the application form and re-read the entered information to ensure everything is complete and correct. Your attached documents should be legible and in the acceptable file formats.
Follow Up On Application Status
You must track your Medicaid credentialing application status preferably after 30-35 days. You can do this via the portal’s dashboard or by calling your state Medicaid agency (SMA). Keeping a tab will help you avoid potential delays and rejections.
Hire Credentialing Experts
The best piece of advice we can give you is to hire a credentialing expert if your budget allows it. Instead of fretting over lengthy applications, countless documents, and back-and-forth emails, you can focus on what you do best — render quality patient care — and let credentialing specialists handle the hassle. There are several reputable medical credentialing companies out there that can file a Medicaid credentialing application on your behalf and get you enrolled in the network within a few weeks.
Simplify Your Medicaid Credentialing with MediBillMD
Whether you want to expand your patient base, improve your reputation, get access to valuable resources, or increase your bottom line, Medicaid provider credentialing can help you with that and more. Your entry into the statewide health insurance network would automatically mean that you have achieved compliance and garnered trust. But is it really that easy to become a Medicaid-approved provider? NO. You must go through their tedious credentialing process to become an in-network provider.
The good news? At MediBillMD, we have an expert team of credentialing specialists who simplify the process and get you credentialed in weeks without any hiccups. Our insurance credentialing services are designed to provide end-to-end assistance, so that you don’t have to struggle with documentation management, revalidation, or re-credentialing.
