Credentialing & Enrollment

Before accepting cash for Medicare-covered NP care, review opt-out eligibility, affidavits, private contracts, effective dates, and renewal obligations.

10. Doula care A Medicaid Doula Benefit Still Needs an Enrollment Plan Coverage is the beginning of the workflow A state announces Medicaid coverage for doula services. Families begin asking whether a local doula can accept their plan. The benefit creates an opportunity, but the answer depends on more than the announcement. The practice needs to review provider eligibility, enrollment, the member’s coverage arrangement, covered services, and the submission process. Doula supp

Use the actual credential from the first application A payer application asks the practice to identify its provider type. The clinician is a midwife, but that broad description may conceal the information the payer needs to evaluate the application. Certified nurse-midwife, certified midwife, and certified professional midwife are distinct credentials. The American College of Nurse-Midwives provides a comparison of their education, certification, licensure, and practice chara

Clinical collaboration and claim reporting answer different questions An NP practice has a collaborating physician. Someone then suggests submitting every visit under the physician because the physician already participates with the payer. Before that becomes the billing workflow, ask which rule actually permits it. A collaboration agreement can address clinical or state-law requirements without establishing the claim arrangement for every service the NP provides. Medicare’s

A lactation practice hires a speech-language pathologist. A physical therapy practice begins offering pelvic health services. A maternal health practice brings in a mental health clinician. Each expansion may help patients get care in fewer places. But before the first appointment, the practice has more to do than update its website. Who will provide the service? How will that clinician participate with each payer? What documentation supports the care? Which benefits apply? W

Wildflower Health has issued a new Cigna Lactation Statement of Work effective October 1, 2026. Providers are understandably noticing the reimbursement increase. The prior agreement paid $175 for an in-person lactation consultation. The new agreement increases that to $182 in most states and $193 in California, Hawaii, Massachusetts, New Jersey, New York, Oregon, Washington, and Washington, D.C. Virtual visits remain $100 and visits involving multiples remain $230. But the ra

There is an important distinction providers—and health plans—need to understand: Being a virtual-only provider is legitimate. Listing a mailbox or virtual mailing address as though it were a physical practice location is something entirely different. Providers increasingly deliver care through telehealth, mobile services, home visits, and other nontraditional practice models. Major payers have systems designed to accommodate those models. You do not need to pretend to have a

For months, California Assembly Bill 2160 generated excitement within the lactation community because it proposed something many advocates have been seeking for years: allowing International Board Certified Lactation Consultants (IBCLCs) to enroll directly as Medi-Cal providers and bill independently for lactation services. Unfortunately, after recent amendments, that proposal is no longer part of the bill. While AB 2160 remains active in the California Legislature, the legis

Effective July 1, 2026, Connecticut officially became one of the few states to license lactation consultants. While many providers have viewed this as a positive step toward greater professional recognition, the new law also raises important questions for independent practices—particularly for Certified Lactation Counselors (CLCs) and other professionals who have historically provided compensated lactation services. Here’s what every lactation provider should know. What Chang

Texas has taken another significant step toward improving access to lactation care. With the adoption of Title 1, Part 15, Chapter 354, Subchapter Q – Lactation Consultation Services, the Texas Health and Human Services Commission (HHSC) has established administrative rules governing Medicaid coverage for lactation consultation services. For IBCLCs and other qualified lactation professionals, this represents an important milestone. While the details of enrollment and reimburs

One of the most common questions we hear from IBCLCs is: "My local Blue Cross Blue Shield plan won't credential me. A company says they can get me paid anyway. Should I sign?" Before you do, it's important to understand how Blue Cross Blue Shield claims generally work. Blue Cross Blue Shield Is Not One Insurance Company Many providers think BCBS is a single nationwide insurer. It isn't. The Blue Cross Blue Shield system consists of independent, locally operated companies. Eac

One of the most common areas of confusion for new and growing IBCLC practices is the difference between an Individual NPI (Type 1) and a Group NPI (Type 2). Understanding when you need each—and how different insurance companies use them—can save you significant time and frustration during credentialing. What Is an Individual (Type 1) NPI? A Type 1 NPI identifies an individual healthcare provider. Every IBCLC who bills insurance should have their own Type 1 NPI. This number fo

In today’s competitive market, businesses face increasing pressure to maintain high standards and comply with industry regulations. Credentialing companies offer specialized services that help organizations verify qualifications, licenses, and certifications efficiently. Partnering with these companies can unlock significant benefits, from saving time to reducing risks. This post explores the key advantages of working with credentialing companies and how they can support your