Can I bill an insurance company before my credentialing is completed?

If you have applied for credentialing but it isn’t complete, billing insurance depends on the policies of the specific insurance company. Here’s what you need to know:

1. "Retroactive Credentialing" Policies

Many insurers allow for retroactive credentialing once the process is approved. This means that:

• You can provide services while credentialing is pending.

• Once credentialing is approved, you can submit claims retroactively for services delivered during the pending period.

• The retroactive billing period is often limited (e.g., 30-90 days prior to credentialing approval).

Important: Not all insurers offer retroactive credentialing. You must verify this directly with the payer.

2. Billing as an "Out-of-Network" Provider

If you are not yet credentialed, the insurer will typically consider you out-of-network, and:

• You may still be able to provide services.

• Patients may face higher out-of-pocket costs, and you’ll need to notify them upfront.

• Claims submitted will be reimbursed at out-of-network rates, if at all.

This approach risks patient dissatisfaction and lower reimbursement rates.

3. Billing Under a Group or Supervising Provider

If you work in a group practice or with a supervising provider who is credentialed:

• Some insurers allow you to bill under the group’s NPI or the supervising provider’s NPI while your credentialing is pending.

• This arrangement often requires compliance with strict supervision rules and varies by payer.

• You should confirm this practice with the insurer to avoid billing violations.

4. Medicare/Medicaid Specifics

• Medicare: You cannot bill Medicare until credentialing is complete. Retroactive billing is possible for up to 30 days prior to your approval date (or 90 days in certain emergency scenarios).

• Medicaid: Policies vary by state, but typically, you cannot bill until credentialing is finalized.

5. Patient Communication

While waiting for credentialing, you should:

• Be transparent with patients about your credentialing status.

• Inform them of possible out-of-network charges.

• Explore options for retroactive billing with the insurer.

Key Takeaways

• Check with the insurer for their retroactive billing and credentialing policies.

• If allowed, document all communications and dates of services carefully.

• Billing before full credentialing can risk claim denials or fraudulent billing concerns if you’re not following the insurer’s rules.

This Q&A does not constitute legal, accounting, or tax advice and

does not address state or local law.