Did you Know?

These are some of the most common questions I get and things providers usually don’t know. And honestly, why would you? No one teaches this. These are just a few nuggets I’ve picked up over the last five years.

• Anthem requires CAQH re-attestation every 90 days. This is important for maintaining your in-network status. If you manage your own CAQH, set a reminder to re-attest every 90 days so this doesn’t get missed.

• Enrolling in Electronic Remittance Advice (ERA / 835 / payment reports) allows payments to post automatically in your EHR. This is a big part of streamlining your billing process. If you’re billing insurance, make sure your EHR supports ERA enrollment.

• Kentucky Medicaid, Medicare, and Tricare East require claim-filing enrollments to be completed and approved (for most EHRs) before you can submit claims through your EHR. However, you cannot complete claim-filing enrollments until you are fully credentialed and in network with the insurance payer.

• Kentucky Medicaid revalidation is required every 5 years. This means you must review and resubmit your enrollment every five years. Keep your contact information accurate on both your individual and group enrollments so you don’t miss important notices.

• You need weekly admin time on your calendar, especially if you’re in-network with insurance. If you can’t keep up with practice management tasks, it may be time to reassess your maximum client load. For practice owners with multiple clinicians, this is even more important unless tasks are delegated to admin staff.

• Traditional Medicare rates are set federally, which generally means higher reimbursement.

• Medicare Advantage plans are managed by individual insurance companies. You are not automatically in-network with Advantage plans unless Medicare is included in your contract with that payer. You would need to request a contract amendment to add Medicare line of business/network for that payer.

• UnitedHealthcare and Cigna Evernorth only offer “group contracts” once you have 5–6+ providers on your roster. Until then, they typically contract providers individually. Don’t get confused by the language — you can still bill under your group NPI and TIN.

• Kentucky Medicaid Provider Type 66 (Behavioral Health Multi-Specialty Group) requires at least two providers on the enrollment application to be eligible for credentialing. WellCare also requires this and asks for a brief clinical description (you can access it here).

• Timely filing limits are typically 90 days for commercial payers and 365 days for Medicaid and Medicaid MCOs. Missing these deadlines usually means the claim will not be paid.

• CareSource recently discontinued its commercial plans in Kentucky. This means clients who previously had CareSource commercial coverage no longer do and will have different insurance.

• Anthem Commercial is one of the most common payers in Kentucky, but also reimburses at some of the lowest rates.

• If you need to contact Anthem about anything, use the chat feature in Availity: Payer Spaces → Anthem → Chat with Payer. This is often faster and better documented than phone calls.

• Kentucky Medicaid requires a copy of your Social Security card (showing work authorization, if applicable) for provider enrollment and credentialing.

• If you submit a credentialing application, always confirm receipt. If something is missing, payers often will not notify you — the application can just sit without being processed.

• Make sure you authorize payers to access your CAQH profile for every payer you want to credential with. If they can’t see your profile, they can’t process your application.

• If you no longer want to be in-network, you must terminate your contract with the payer. You cannot charge a patient self-pay if you are in-network and they want to use their insurance — that’s in your contract with the insurance payer.

• Couples therapy (90847) is reimbursed at a lower rate than individual therapy (90837) by most commercial payers.

• Some patients with commercial insurance may have out-of-network benefits. They can call their insurance company to check — I’ve created a call script they can use.

Stay tuned for more! If you have questions about anything I've mentioned, schedule a consult with me here!