This is an overview of some of the items you should have in place before your start the contracting and credentialing processes with insurance plans:
Solo-Practitioner vs Group (SSN vs EIN)
You will need to decide if you are going to operate as a solo-practitioner or as a group. If you are going to operate as a group, you will be a LLC, Individual/Sole-proprietor LLC, C-Corporation, S-Corporation, or Partnership and you will then need to have a group name, an Employee Identification Number (EIN) and Group/Type 2 NPI. Please note, if you are going to operate using an EIN and you are the only provider in your practice, the insurance plans will recognize you as a group entity and not an individual provider. This can be an important distinction when you communicate with the insurance plans.
If you are considering operating ‘as a group’ but think you want to hold off and do it in the future, it may be worthwhile to accomplish these steps now, while you are initially setting up your practice and before you contract with any insurance plans. Setting up a group practice make take a few more steps initially, but it can save you time later. Some plans require you to submit a whole new application to change from an individual to group practice, any EFT agreements will have to be redone and it may have a temporary impact on your billing timeliness. In short, while doable to change this later, it can become more complicated.
Another major distinction between operating as an individual vs group practice is how you bill. If you use an EIN, your billing will be done under the EIN (and group’s NPI number, more on this below) and you will be rendering provider under that group.
An Employee Identification Number is required if your practice is going to be a LLC, Individual/Sole-proprietor LLC, C-Corporation, S-Corporation, or Partnership. This can be obtained from the IRS at: https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online
Type 1/Individual NPI number
Every provider has to have an individual (also referred to as a Type 1) National Provider Identifier (NPI) number. This can be obtained through NPPES: https://nppes.cms.hhs.gov/#/
Type 2/Group NPI
A group (also referred to as a Type 2) NPI number is necessary if you plan to operate as a group and use an EIN. This can also be obtained through the same account you used to obtain your Type 1 NPI: https://nppes.cms.hhs.gov/#/
The turnaround time to getting an NPI number is typically 2-3 days.
You will need to have a practice location and this will need to comply with industry standards for a place of business. If you rent or office share with someone, you may need to use the address for contracting with the plans prior to your start date in using the space, so make sure that is agreed upon.
You will need to have a business license in order to apply with Medicaid. You should contact your county to obtain this. Depending on the county, this can take some time to obtain.
You will need to have malpractice insurance to cover yourself and/or your group practice. This could be obtained through your national providers association (such as NASW), your personal insurance company or insurance companies that specialize in malpractice insurance, such as HPSO. Obtaining insurance can take up to 2-3 days, but usually goes pretty quickly.
Insurance plans will have to credential you, which is how an insurance plan checks to see if your education, licensures, insurance, work history, etc. are valid, verified and up to date. CAQH is the common credentialing platform used by insurance plans. It is important that you keep your CAQH account update date and that you re-attest the information there is update to date every three months. To set up your CAQH account, go to Proview: https://proview.caqh.org/Login/Index?ReturnUrl=%2f
If you plan to offer services to the Medicaid population, you must apply and register with Medicaid. Conduent is the registrar for the NM Medicaid providers. To register as an individual, you will use Provider Participation Agreement (PPA) MAD 312. In addition, if you are operating as a group, that will also need to be registered. You will use Provider Participation Agreement (PPA) MAD 335. All of this is done through Conduent’s online Medicaid application portal at: https://nmmedicaid.portal.conduent.com/webportal/enrollOnline
Contact them with questions at:
1-800-299-7304 or 505-246-0710.
Typically, Medicaid applications take about 6 weeks to process, but that is not a guarantee.
Please note, once you are registered with Medicaid, you will still need to contract with the insurance plans that administer NM Medicaid (BCBS, Presbyterian and Western Sky Community Care) in order to see any Medicaid member(s) that are enrolled with any of those three insurance plans.
Supervisory Certification (BHA 432)
To bill Medicaid for non-independently licensed providers (NIL), you must be an approved Supervisor and an approved Specialty (most likely an approved Behavioral Health Agency, provider type 432). To learn about the process to be a supervisor, please see these resources:
Provider Tool Kit
The Behavioral Human Services Division (BHSD) has a Provider Took Kit booklet, which also covers some of this same information:
You should consider having an attorney, CPA or a biller confer with you before or during this process. They can help ensure that your practice’s structure is being set up correctly and confer on which one will work best for you.