Contracting and credentialing can be a very time-consuming and overwhelming process for ABA services. These processes can take potentially between 30-180 days or more — depending on the payer — and requires intensive follow up. The information that makes up the contracts and credentialing affects every claim that is billed, so if something is incorrect, the claim will be denied which will lead to more time and money being spent to correct the contracting process.
This is why it’s so important that ABA consultation and service providers understand the difference between contracting and credentialing, as it can have a major impact on efficiency with payers in the healthcare industry. Join us as we take you through contracting and credentialing in our guide for beginners, and how Missing Piece, one of the leading ABA therapy billing services, can help.
What is the difference between credentialing and contracting?
Contracting and credentialing are both important in a service provider’s relationship with a payer, but how do they differ?
What is Contracting?
Contracting is the process of becoming in network with a payer. When complete, both you and the payer will sign the contract which outlines the conditions or terms of the agreement and obligations of each party. As a provider, it is critical that you understand your obligations to the payer. Each payer’s contract is very different, and your obligations may be as well. Be sure you understand these and seek guidance from professionals as needed. Some payers will offer group contracts, and some offer individual contracts with behavioral health and ABA providers.
What is Credentialing?
Credentialing is the process that payers use to verify a provider’s credentials, and to ensure that they meet the standards required by that payer to render services; this may include documents such as licenses or certification, and professional liability insurance. Each payer will have different standards that providers are required to meet.
The role of NPI numbers in the claims process
ABA billing codes aren’t the only numbers ABA therapy providers must know. NPI numbers are also another important element that ABA providers must provide during the claims process.
What is an NPI number?
NPI stands for National Provider Identifier. This is a number that is used to identify either an individual or a group healthcare provider. These numbers were established as an alternative to the use of Social Security numbers as an identifier, and are required to bill claims. The NPI registry is managed by the US Centers for Medicare and Medicaid and the Department of Health and Human Services. Having an NPI number does not guarantee that the provider or organization has valid licensing or certification. It is simply an assigned number used for identification purposes.
Types of NPI numbers
There are two types of NPI numbers: Type 1NPIs and Type 2 NPIs.
Type 1 NPI
Individual providers should keep in mind that the Type 1 NPI will stay with the provider regardless of employment, so the individual provider is responsible for retaining their login and password information to maintain their NPI profile. The set-up process to obtain a NPI number is relatively quick. To establish a Type 1 NPI number or individual NPI, a provider will need the following information:
- Full name
- Telephone number (business and personal)
- Date of birth
- Social security number
- Home address
- Email address
- Taxonomy code
Type 2 NPI
A Type 2 number should be established only for a group or business entity. A business may need one or many NPI numbers. Refer to NPPES for more information. In general, a business will need the following information to establish the NPI number(s):
- Legal business name
- DBA (Doing Business As) name
- Legal address
- Phone number
- Tax Identification number
- Email address
- Taxonomy code(s)
You can find more information or enroll for an NPI here.
The role of CAQH in the claims process
CAQH is another important player in the healthcare industry that ABA providers need to know about in regard to credentialing data.
What is CAQH?
CAQH stands for Council for Affordable Quality Healthcare. This is a non-profit organization established to streamline healthcare credentialing by creating a database for providers to house credentialing documents that payers can access. Prior to the creation of CAQH, providers would have to complete numerous extensive applications for each payer, ultimately repeating similar information on each form.
A provider can either set up their own CAQH profile, or it can be created on their behalf. The CAQH information and identifying number will remain with the provider regardless of employment; therefore it is important for the provider to be knowledgeable about their account and login information. This information may change as employment changes, and will need to remain current. To set up CAQH credentialing for the first time, a provider will need the following information:
- Full name
- Personal phone number
- NPI number
- License or certification information
- Employment information
- Tax ID
- Group NPI
- Practice locations
- Educational background including degrees and locations of schools attended
- Prior employment history including locations, as well as, explanation of employment gaps of six months or more
- Professional liability insurance information and face sheet
- Taxonomy code
You can set up or access CAQH here.
How do I get started with contracting and credentialing with payers?
Missing Piece has helped hundreds of ABA providers with their contracting and credentialing needs. Whether it is strategizing with you about your network’s status, or providing guidance through fee-scheduled negotiations, we are here to help maintain and keep your payer group contracts in the most current status possible. We know firsthand that contracting and credentialing require extensive documentation and follow-up, which is why we work alongside you during this process. Whether it’s ABA task code billing, pre-authorization, or proactive monitoring of claim acceptance, we take care of all the details to help give you peace of mind that everything is done quickly, efficiently, and correctly, ensuring you receive your reimbursement as soon as possible.
To learn more about how our comprehensive revenue cycle management process can help your organization, contact us online or by phone at 765-628-7400.