Before You Credential with Insurance Panels: Read This First

If you are considering credentialing with insurance payers, read this! Or share this with someone you know who might be interested in becoming and in-network provider. Insurance credentialing is nuanced, it's important to have clarity on what your practice goals are before starting the process. This is the #1 reason I encourage prospective clients to schedule a 15 minute consult with me before working together.

Individual (Solo) Agreements vs. Group Contracts

There are two ways to credential with insurance payers:

1. As an Individual/Solo Provider

2. As a Group (using a Group NPI and TIN)

Understanding the difference matters — especially if you plan to grow.

Solo Provider Contracts

Best for clinicians who do not plan to add other providers under their tax ID.

Key points:

• Does not require a Group NPI (Type 2 NPI)

• Does not require a TIN (you may use your SSN, though many still obtain a TIN)

• You cannot credential other providers under your contract

• If enrolling with Medicaid MCOs, you are only required to complete Individual Medicaid Provider Enrollment

Important: If you later decide to become a group, you will need to re-credential with payers under the new structure.

Group Contracts

Necessary if you plan to credential multiple providers under one entity.

Requires:

• A TIN

• A Group (Type 2) NPI

• Group Medicaid Provider Enrollment (if enrolling with Medicaid)

• Individual Medicaid Provider Enrollment for each clinician linked to the group

Benefits:

• You can credential multiple clinicians under one tax ID

• Centralized billing under the group

• Easier growth structure

  
  

Kentucky-Specific Note

Two commercial payers in Kentucky typically do not issue traditional group contracts unless you have 5+ providers:

• Cigna Evernorth

• UnitedHealthcare (issues group contracts only if specific criteria are met)

This does not mean you cannot credential as a group.

It means:

• You may use your Group NPI and TIN

• Each provider will receive an individual agreement

• Any demographic updates (address change, etc.) must be completed for each individual provider

Many practice owners don’t realize this until they need to update something.

Identifying Projected Income

Before applying to insurance panels, you should know:

• How much money you need

• How much money you want

• How many sessions per week that requires

Example: 53–60 minute session (CPT 90837) – Kentucky Averages

(Rates fluctuate; always verify current fee schedules.)

• Anthem: ~$91

• Other Commercial Plans: ~$100 average

• Medicare: ~$110 average

• Medicaid: ~$89

Understanding reimbursement allows you to calculate:

• Weekly session targets

• Monthly revenue projections

• Whether insurance aligns with your goals

If you’re in-network with insurance, plan for:

• 1–2 hours per week minimum for administrative work(claims follow-up, authorizations, eligibility checks, documentation)

If you are managing other clinicians, your clinical hours should be reduced to account for practice management responsibilities- It's no sustainable to do both.

Building Your Referral Network

Private practice can feel isolating. Proactive networking matters.

Consider:

• Staying connected with colleagues from prior workplaces

• Scheduling in-person meetings with agencies serving your population

• Joining professional organizations (consider board or committee roles)

• Being active in professional social media groups

• Maintaining a strong Psychology Today profile

Stay consistent.

Medicaid: Choosing a Provider Type

If enrolling as a group with Kentucky Medicaid, you must select a provider type.

Not all provider types apply to behavioral health.

Each provider type has:

• Specific regulatory requirements

• Rules about which clinicians can be linked

• Scope limitations

Review the provider type summary carefully before enrolling.

Medicare & Advantage Plans

If you plan to accept Medicare and want to be in-network with Advantage plans:

1. Complete Medicare enrollment first.

2. After approval, you will receive a PTAN (Medicare number).

3. Use your PTAN when credentialing with commercial payers and MCOs.

4. This prompts inclusion in Medicare Advantage networks.

Skipping this requires contract amendments in order to be in network with Medicare Advantage plans.

Your credentialing structure impacts:

• Income

• Growth

• Administrative burden

• Long-term flexibility

Many providers choose a structure without fully understanding the implications — and end up redoing it later.