Medicaid credentialing is the enrollment we are most often called in to rescue. It is nearly always the same story. The practice enrolled with the state program, received an approval, started seeing patients, and then discovered that the managed care plans those patients are actually enrolled in were a separate application nobody filed.
For the work itself, see our medical credentialing services.
Two steps, always
State first, then every plan
Step one: enroll with the state Medicaid agency. This gets you a Medicaid provider number and lets you bill fee-for-service Medicaid.
Step two: enroll separately with each managed care organization contracted in your region. The large majority of Medicaid members are in managed care, so step two is where most of your actual patients are. Finishing step one and stopping means you are enrolled with a program that covers a minority of the population you intended to serve.
Most states require the state enrollment to be complete before an MCO will process your application, so the steps are sequential rather than parallel. Budget for both.
Screening levels
Federal rules put every enrolling provider into a risk category, and the category determines what you have to go through:
| Risk level | Typically includes | What is required |
|---|---|---|
| Limited | Physicians, most practitioners, group practices | License verification, database and exclusion checks |
| Moderate | Hospices, some agencies, independent testing facilities | The above plus unannounced site visits |
| High | Newly enrolling DMEPOS suppliers and home health agencies | The above plus fingerprint-based criminal background checks on owners |
Application fees apply to institutional providers in many states. Knowing your category up front tells you whether to plan for 60 days or 120.
Virginia
We are based in Fairfax, so Virginia is the program we work in most. Virginia Medicaid is administered by the Department of Medical Assistance Services, with most members covered through its managed care program and a set of contracted health plans delivering the benefit.
- Enroll with the state program through the provider enrollment portal first.
- Then enroll with each contracted managed care plan operating in your region. That is where the members are.
- Behavioral health services have their own service authorization and registration requirements, which are additional to enrollment.
- Providers serving members across the DC metro area often need Maryland and District enrollment as well; each is a separate program with separate rules.
Program names, plan rosters and portals change, so we confirm current requirements at the point of filing rather than working from a saved checklist.
Revalidation
Medicaid requires revalidation at least every five years, and some states more often for higher-risk categories. As with Medicare, the notice goes to the contact on file and deactivation for a missed deadline stops payment rather than reducing it. We track the dates.
Behavioral health and ABA
Medicaid is the largest payer for behavioral health and for ABA, and it is the strictest. Depending on the state you may need named registration of every technician, documented supervision ratios, a diagnosis from an approved provider type before services begin, and service authorization separate from enrollment.
- Therapists and counselorsInsurance credentialing for therapists
- ABA agenciesABA credentialing services RBT registration and state program differences
What causes delays
- Assuming the state enrollment covers the managed care plans
- Ownership disclosure sections left incomplete: these are scrutinised closely
- Address mismatches between the application, W-9, license and NPPES
- Missing a scheduled site visit for a moderate or high risk category
- Filing before the state enrollment is finalised, so the MCO rejects on sequence
Free enrollment check
Tell us your state, provider type and the plans your patients carry. We will map the state enrollment and every managed care plan you actually need.
Free credentialing check Talk to a credentialing specialist