It depends on the payer. A Texas Medicaid managed care plan has to treat a licensed professional counselor, marriage and family therapist, clinical social worker or psychologist who joins a group it already contracts with as in network while it reviews them. Original Medicare starts a clinician's billing on the day it received the application at the earliest, and lets them bill up to 30 days before that in narrow cases. A commercial plan pays before credentialing is done only if its contract says so, because Texas's expedited credentialing law for commercial plans does not cover therapists.
Owners hear "Texas has expedited credentialing" and plan a new hire's first month around it. For commercial plans that is true of physicians, not of the clinicians a therapy practice hires. A session billed under a plan that has not finished credentialing the clinician comes back as an out-of-network denial, or is paid and later taken back. The post on how long a caseload takes to fill covers what the wait does to a hire's first months. This one covers what each payer allows during it.
What does each payer allow?
Texas Medicaid managed care
The rule is the strongest one a therapy practice has. Each Medicaid plan "must establish and implement an expedited credentialing process" for licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists and psychologists (1 TAC §353.423(b)).
To qualify, the clinician has to meet four conditions:
- They join "an established health care provider group that has a current contract with an MCO".
- They are already a Medicaid-enrolled provider.
- They agree to the group's contract terms.
- They submit everything the plan needs to begin credentialing.
Once they have, "the MCO must treat the provider as if the provider were in the MCO's provider network" for Medicaid payment. The rule speaks of Medicaid reimbursement, so ask the plan in writing whether it applies the same treatment to its CHIP members.
The rule has two catches. If the clinician fails credentialing, the plan may recover "the difference between payments for in-network benefits and out-of-network benefits". If the application was fraudulent, it may recover "the entire amount of any payment". So the application has to be complete and true.
The order matters. A clinician who is not yet enrolled with Texas Medicaid through TMHP does not qualify, so enroll with TMHP first and send the plan applications the day enrollment is confirmed.
Medicare
Medicare pays licensed marriage and family therapists and mental health counselors who enroll on their own, since January 1, 2024 (CMS). The regulation sets the effective date for physicians and non-physician practitioners. We read that as including these clinicians, and Novitas Solutions, the Medicare contractor for Texas, can confirm it. The effective date of billing privileges is "the later of" the date Medicare received an application it later approved, or "the date that the provider or supplier first began furnishing services at a new practice location" (42 CFR 424.520(d)).
So the filing date is the earliest a clinician can usually bill from. A clinician may bill for services up to "Thirty days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries" (42 CFR 424.521(a)). The same rule requires that they met every program requirement, state licensure included, and that the services were provided at the enrolled practice location. After a federally declared disaster the window is 90 days. That is a narrow exception, not a grace period. Send the Medicare application before the clinician's first day, with the clinician's reassignment of benefits to the group, and don't book an Original Medicare client with them until the effective date is in writing.
Medicare Advantage is a different payer for this purpose. Its plans credential clinicians on their own schedule, like a commercial plan, so a Medicare Advantage client waits for that plan's approval.
Commercial plans
Texas has an expedited credentialing law for commercial plans, and it does not reach therapists. Its subchapters cover physicians, podiatrists and therapeutic optometrists. The physician subchapter says it "applies only to a physician who joins an established medical group" (Texas Insurance Code §1452.102). A Medicaid rule cites the same three subchapters and then adds the therapy professions for Medicaid only, which is the gap in one sentence.
Is there any deadline for a commercial plan? For HMOs, TDI says that under 28 TAC §11.1402(c), an HMO must tell an applicant in writing whether it is accepted "no later than 90 days from receipt of an application for participation" (TDI, HMO provider credentialing requirements). We found no day count for PPOs. And TDI says "Legitimate self-funded ERISA plans established by a single employer for the employer's own employees" are "generally exempt from state regulation" (TDI Commissioner's Bulletin B-0009-02), so its administrator's contract is the only rule.
Some contracts let a group bill for a new clinician from the application date, or backdate the effective date once credentialing is done. Ask each plan in writing before you rely on either, and keep the answer with the clinician's file.
What should the clinician see in the meantime?
Self-pay clients, Medicaid clients under plans that accepted the expedited application, and clients under any plan that has finished. Each self-pay client needs a Good Faith Estimate. The guide to the Good Faith Estimate covers what it has to say. A client whose plan has not finished goes to an established clinician or waits, with their consent. And don't bill a session under another clinician's name to bridge the wait unless the payer has said in writing that it allows it. The post on LPC Associates covers the questions to ask.
What to do this week
- For each clinician who started in the last six months, list every payer and the date each application was sent, accepted and approved.
- For each Medicaid plan, check that the clinician was Medicaid-enrolled before the plan application went in, and that the plan confirmed the expedited process in writing.
- Check every Medicare application's effective date, and that no Medicare session was billed before it.
- Ask each commercial plan in writing whether it pays for a new clinician from the application date, and whether it backdates the effective date.
- For the next hire, start the TMHP enrollment linked to your group, the Medicare application with its reassignment to the group and the CAQH profile the week the offer is accepted.
Sources
- 1 Texas Administrative Code §353.423, expedited credentialing.
- 42 CFR 424.520, effective date of Medicare billing privileges.
- 42 CFR 424.521, request for payment by certain provider and supplier types.
- Marriage and family therapists and mental health counselors, Centers for Medicare and Medicaid Services.
- Texas Insurance Code §1452.102, applicability of expedited credentialing for physicians.
- HMO provider credentialing requirements, Texas Department of Insurance, updated July 3, 2023.
- Commissioner's Bulletin B-0009-02, Texas Department of Insurance, March 22, 2002.
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