The shift in CAQH’s status from a nonprofit industry utility to a payer-owned data system is arguably the most significant administrative change for healthcare providers in 2026. This move has transformed CAQH from a passive “filing cabinet” into an active revenue gate.

Here is a detailed breakdown of the ownership shift and the resulting “soft freeze” phenomenon.

1. The Ownership Shift (January 2026)

As of early 2026, CAQH is now officially owned by a consortium of 12 major health plans, including UnitedHealth Group, Centene, Aetna (CVS Health), Elevance Health, Cigna, and Humana.

• From Neutral to Governed: Previously, CAQH was a nonprofit that served both providers and payers. Now, it is a shareholder-owned company. The Board of Directors is chaired by executives from the very insurance companies you bill.
• The Incentive: Payers took ownership to accelerate Interoperability and Data Integrity. Their goal is to eliminate the cost of “dirty data” (incorrect addresses, expired licenses) which costs the industry billions in claim rejections and directory errors.
• Automated Verification: The new structure has allowed CAQH to integrate directly with 47 state licensing boards. The system now “pulls” your data automatically rather than waiting for you to upload it, and it flags discrepancies in real-time.

2. What is a “Soft Freeze”?

In 2026, the traditional “denial letter” is being replaced by the “Soft Freeze.” This is an automated suspension of claims processing triggered by your CAQH status.

• How it Works: Because payers now own the system, their internal claims engines (like Facets or QNXT) are hard-wired to the CAQH API. Every time a claim is submitted, the system checks: “Is this provider’s CAQH attestation current?”
• The Trigger: If your 120-day re-attestation window closes, your status in the payer’s system flips to “Inactive” or “Non-Compliant” within 24 hours.
• The Result: Your claims aren’t necessarily denied for “medical reasons”; they are simply held in a pending state or rejected with a generic “Provider Not Found” or “Out of Network” error code. This is a “soft freeze” because the money is there, but the gate is locked until the data is refreshed.

3. Critical Changes for Your Practice

Under the new payer-owned model, the “margin for error” has effectively disappeared.

4. How to Prevent a Soft Freeze

To navigate this new environment, you must move from reactive to proactive data management:

1. The 90-Day Buffer: Do not wait for the 120-day deadline. Set your internal calendar to re-attest every 90 days. This ensures that even if there is a processing lag, your status never hits the “danger zone.”
2. Assign a “Data Owner”: Ambiguity is the enemy of revenue. One person in your practice must be responsible for CAQH, NPPES, and PECOS. If these three databases don’t match exactly, the AI-driven “soft freeze” is more likely to trigger.
3. Check the “Roster Status”: Many payers now provide a “Roster Status” tool in their provider portals. Check this monthly to ensure your CAQH “Active” status has successfully synced with that specific payer.
4. Monitor “Silent Denials”: If you see a sudden spike in “Out of Network” denials for a provider who has been in-network for years, check CAQH first. It is the #1 cause of “silent” payment interruptions in 2026.

5 Minutes Every Friday

To stay ahead of the “Soft Freeze” and ensure your practice remains fully compliant in 2026, your office manager should spend roughly 5 minutes every Friday running through this specific checklist.

In this era of AI-driven payer audits, consistency is more important than effort.

🏥 The “Friday 5” Compliance Checklist (2026 Edition)

1. The CAQH “Attestation Buffer” (60 Seconds)

• Action: Log into the CAQH ProView portal.
• Check: Verify that your next attestation date is at least 30 days away.
• Rule: If the deadline is within the next 4 weeks, attest now. Do not wait for the “Soft Freeze” trigger at Day 121.
• AI Tip: Ensure there are no “Incomplete” flags in the profile. Automated payer scrapers will flag a 99% complete profile as “Non-Compliant.”

2. The “Tri-Sync” Audit (60 Seconds)

• Action: Quickly cross-reference the practice’s primary address and Tax ID.
• Check: Do the addresses in CAQH, NPPES (NPI), and PECOS (Medicare) match letter-for-letter?
• Rule: If you moved or changed suites, you must update all three databases simultaneously. AI-driven billing systems flag even minor suite number discrepancies as potential fraud or data errors.

3. Monthly Exclusion Scrub (60 Seconds)

• Action: Check the OIG LEIE or your automated monitoring tool for all staff (providers and admin).
• Requirement: In 2026, NCQA standards have shifted toward monthly monitoring.
• Rule: Confirm that no new exclusions have been posted for your Tax ID or NPIs this month.

4. The “Continuous Query” Notification Review (60 Seconds)

• Action: Check your NPDB (National Practitioner Data Bank) inbox.
• Check: Have you received any “Action” notifications for your enrolled providers?
• Rule: Since most payers now use Continuous Querying, they will see a malpractice or licensing board action within 24 hours. You must address these internally before the insurance company reaches out with a de-credentialing notice.

5. Expiring Documents Queue (60 Seconds)

• Action: Scan your “Expiring Soon” folder or software alerts.
• Check: Are there any Medical Licenses, DEA certificates, or Malpractice Face Sheets expiring in the next 60 days?
• Rule: You must upload the new document to CAQH as soon as you receive it. Leaving an “Expired” document on the portal—even if the new one is sitting on your desk—is the #1 cause of “Silent Denials.”

📅 The Office Manager’s 2026 Schedule

Pro-Tip: If you see a sudden “Provider Not Found” or “Out of Network” rejection for a provider who has been in-network for years, skip the phone call to the payer. Go directly to CAQH; 9 times out of 10, a lapsed attestation or an expired document is the culprit behind the “Soft Freeze.”

The future of credentialing isn’t coming; it’s already here. At MedTrust Provider Advocates, we’ve been the bridge between providers and payers for over 20 years. Whether you’re navigating changes to CAQH, new AI-driven audits or state-specific program shifts, we’re here to be your guide.

What Providers and Members Need to Know

On April 1, 2026, National Government Services (NGS) officially transitioned to a new brand name: Wellpoint Federal. While the name may be new, the organization, services, and systems that providers and beneficiaries rely on will remain largely unchanged. This rebrand is designed to align NGS more closely with the broader Wellpoint identity—without disrupting day‑to‑day operations.

Below is a breakdown of what this transition means, what stays the same, and what actions (if any) are required.

A Brand Change—Not a System Change

The most important takeaway from the transition is that this is primarily a branding update. Providers and beneficiaries currently working with NGS do not need to manually switch systems, re‑enroll, or take corrective action to continue receiving services.

What’s Staying the Same

Despite the new name, Wellpoint Federal will maintain the same operational foundation NGS users are familiar with:

• Operating Model:
  The company structure, service levels, and overall operating model will remain unchanged.
• Claims and Payments:
  There is no expected impact on claims submission, processing, or payment timelines.
• Payer IDs and Electronic Submissions:
  Payer IDs, electronic claim submission processes, and clearinghouse connections will continue as they do today.
• Provider Portals:
  Existing portals—including NGSConnex and NGSMedicare.com—will remain active and functional throughout and after the transition.
• Enrollment and Revalidation:
  No action is required for PECOS enrollment, revalidation cycles, or reassignment of benefits.

For most users, the transition should feel seamless, with no interruption to workflows or access.

What the Name Change Means for Providers

For healthcare providers, the move to Wellpoint Federal does not alter participation status or administrative requirements.

• Current Providers:
  If you are already enrolled or credentialed through NGS, you will continue operating as usual under the Wellpoint Federal name.
• Claims and Administrative Tasks:
  Existing systems, submission methods, and timelines remain intact, helping ensure continuity and predictability.
• Support and Assistance:
  Provider Services will continue to be available, and official updates will be communicated through established channels.

Interested in Joining the Network?

Providers who are new to Wellpoint Federal and wish to participate can begin the process by contacting the dedicated team at MedTrust Provider Advocates.

What Members Should Expect

For Medicare and Medicaid members, the rebrand does not affect eligibility, benefits, or access to care.

• No Disruption to Coverage:
  Existing plans remain active, and there is no need to re‑enroll due to the name change.
• Plan Options:
  Individuals interested in Medicare Advantage or Individual & Family plans can explore and enroll directly through the Wellpoint website.
• Account Management Tools:
  Members can continue to manage their coverage using familiar digital tools, including:
  • Secure member portals
  • Virtual ID cards
  • Primary care physician selection and updates

These features are also accessible through the Sydney Health mobile app, offering convenient, on‑the‑go account management.

Why the Transition Matters

While operationally simple, the transition to Wellpoint Federal reflects a broader brand alignment that may bring long‑term benefits, including clearer brand recognition and a more unified experience across plans and services. Importantly, the organization has prioritized continuity, ensuring that providers and members can focus on care—not administrative changes.

Where to Get More Information

For the most up‑to‑date details on the rebrand or for personalized assistance:

• Providers can contact Provider Services
• Users can visit the National Government Services website for official updates and announcements

Final Thoughts

The transition from National Government Services to Wellpoint Federal marks a new chapter in name—but not in function. With no required action for existing providers or members, stable systems, and continued access to familiar tools, the change is designed to be smooth and minimally disruptive.

At a glance:

• Effective March 1, 2026: ABA service reimbursement will be based on weekly approved units instead of total authorized units.
• Action required: Review authorizations, update billing systems, and educate staff to align with the new weekly structure and prevent claim delays.

New weekly structure for ABA service reimbursement starts in 2026

Effective March 1, 2026, reimbursement for Applied Behavioral Analysis (ABA) services will be based on weekly approved units rather than total authorized units.

This change helps streamline claim processing, ensure consistency in service delivery, and reduce administrative adjustments. No action is required for existing requests and claims, including those submitted before the effective date and those with date ranges that extend beyond it.

Supporting access to ABA care for members

Transitioning to a weekly unit structure helps members access care reliably by promoting timely, appropriate ABA services and reducing service disruptions caused by administrative delays.

How this change affects your billing and claims submissions

We encourage care providers to familiarize themselves with these changes to ensure compliance and continuity of care.

Claims should reflect the units rendered within each week, up to the weekly medically necessary limit as approved by prior approval. Claims submitted with units exceeding the weekly limit will be considered ineligible for reimbursement and will be adjusted accordingly.

Steps to prepare your practice and prevent claim delays

To ensure a smooth transition and avoid claim issues or payment delays:

• Review your upcoming authorizations to identify the weekly approved units.
• Update your internal billing systems and scheduling processes to align with the new weekly authorization structure.
• Educate staff responsible for claims submissions to ensure they are informed and prepared to implement this change.

Affected CPT^® codes

For years, healthcare credentialing was synonymous with a “paper mountain” a slow, manual slog of faxes, phone calls, and endless follow-ups. But as we move into 2026, a quiet revolution has taken place. Artificial Intelligence (AI) has moved from experimental pilot programs to becoming the core infrastructure of insurance credentialing and provider enrollment.

If your practice isn’t leveraging AI for credentialing yet, you’re likely losing more than just time. Here is how AI is reshaping the landscape this year.

The $1 Million Disconnect: ROI is the New Headline

A striking industry report from February 2026 reveals that healthcare organizations are losing an average of $1 million annually due to credentialing bottlenecks. Despite this, many systems only allocate 12% of their AI budget to administrative tasks, favoring clinical tools that make flashier headlines.

The 2026 Reality: The most profitable practices have flipped this script. By using AI to automate the “low-value” work—like extracting data from scanned licenses or pre-filling payer forms—organizations are seeing a 90% increase in team efficiency. The goal in 2026 is “Top of License” work: let the AI handle the data entry so your staff can focus on high-level strategy and payer relationships.

CAQH 2.0: Payer Ownership Meets AI Audits

In a major structural shift this year, a consortium of leading health plans took ownership of CAQH. This means CAQH is no longer just a neutral database; it is a payer-governed access point.

• The AI Audit: Payers are now using advanced AI “scrapers” to scan CAQH profiles at scale. These systems detect patterns and subtle discrepancies between your tax IDs, practice addresses, and licensure data across multiple systems (PECOS, NPPES, and internal records).
• The 2026 Consequence: If your CAQH attestation lapses by even a day, AI-driven claims engines may now automatically “soft-freeze” payments. In 2026, a clean CAQH profile is as critical to your cash flow as the clinical care you provide.

Agentic” Credentialing: Beyond Simple OCR

Last year, we talked about OCR (Optical Character Recognition) reading documents. In 2026, we’ve moved to Agentic AI.

These aren’t just tools; they are “agents” that can observe, plan, and act. An AI credentialing agent can now:

• Proactively Clear Blockers: It doesn’t just wait for a rejection; it can predict a delay in a primary source verification and initiate a follow-up email to a state board before a human even realizes there’s a lag.
• Intelligent Form Mapping: The AI now “understands” the nuance of different state requirements, automatically adapting a provider’s packet to meet specific Texas vs. Massachusetts mandates without manual re-entry.

The Human-in-the-Loop: Trust and Governance

With the rise of AI, 2026 has also brought a surge in Regulation and Accreditation.

• URAC AI Accreditation: This has become the gold standard this year. Organizations are seeking this accreditation to prove that while they use AI for speed, they maintain “meaningful human oversight.”
• State Transparency Laws: New laws (like California’s AB 2013 and Texas’s TRAIGA) now require developers to disclose the data used to train their AI. In short: insurers can use AI to verify you, but they must be transparent about how those algorithms are making decisions.

2026 Strategy: How to Level Up

To thrive in this automated era, your practice needs to move from “processing” to “exception handling.” 

Automate the Mundane: Use an AI-powered platform for primary source verification (PSV) and exclusion monitoring.

Audit Your Data: Ensure your information is identical across PECOS, NPPES, and CAQH. AI audits look for “mismatches” as a primary trigger for denials.

Monitor CAQH Daily: Don’t wait for the 90-day reminder. Treat your CAQH profile like your practice’s credit score—monitor it constantly to prevent revenue interruptions.

The future of credentialing isn’t coming; it’s already here. At MedTrust Provider Advocates, we’ve been the bridge between providers and payers for over 20 years. Whether you’re navigating new AI-driven audits or state-specific program shifts, we’re here to be your guide.

As we move further into 2026, the landscape for mental health professionals is undergoing a major structural shift. Between state-level program overhauls and new federal standards for parity, the “business” side of therapy is requiring more attention than ever.

If you feel like the goalposts for insurance contracting keep moving, you aren’t alone. Here is the latest news you need to know to keep your practice running smoothly this year.

The Great Ohio Transition: MyCare 2.0

The biggest news currently impacting the Midwest—and serving as a case study for the rest of the country—is the official launch of the Next Generation MyCare Ohio program.

As of January 1, 2026, Aetna Better Health and UnitedHealthcare Community Plan have officially exited the MyCare Ohio market for dual-eligible members. This has left thousands of providers scrambling to ensure they are credentialed with the four remaining “Next Gen” plans:

• Anthem Blue Cross and Blue Shield
• Buckeye Health Plan
• CareSource
• Molina Healthcare of Ohio

The Takeaway: If you haven’t updated your contracts yet, claims for these members under old plans will likely face immediate denials. This transition highlights a growing trend: states are consolidating managed care to fewer, “higher-performing” plans, making it vital for providers to stay nimble.

Federal Parity Enforcement Hits Credentialing

2026 marks a turning point for the Mental Health Parity and Addiction Equity Act (MHPAEA). New federal regulations now require insurance companies to prove that their credentialing processes are not more “restrictive” for mental health providers than they are for medical/surgical providers.

• What’s New: Payers are being audited on their “Network Adequacy.” If an insurance company has a six-month waitlist for mental health credentialing but only a two-week wait for a primary care doctor, they could face significant federal fines.
• The Impact: We are starting to see “closed panels” slowly pry open in areas where mental health access is low. If you were denied by a panel in 2024 or 2025, now is the time to re-apply.

The Rise of “Continuous Monitoring”

Gone are the days when you could “set it and forget it” after your initial credentialing. In 2026, major payers like Aetna and Cigna are shifting toward Continuous Querying via the National Practitioner Data Bank (NPDB).

Instead of waiting for your three-year re-credentialing cycle, AI-driven systems now alert payers instantly if there is a change in your:

• State licensure status.
• Malpractice claims.
• Sanctions or exclusions.

Pro-Tip: Ensure your CAQH ProView profile is attested every 90 days. In 2026, many automated systems will “soft-freeze” your payments if your CAQH attestation lapses by even a week.

Telehealth Credentialing: The “Place of Service” Finality

After years of temporary “emergency” rules, 2026 has brought finality to telehealth billing. CMS and major commercial payers have standardized the requirements for providers practicing across state lines.

• POS 10 vs. POS 02: Make sure you are using the correct code. POS 10 (Telehealth Provided in Patient’s Home) is now the standard for most mental health sessions.
• Interstate Compacts: If you are part of Psypact or the Counseling Compact, ensure your credentialing file with the insurance company specifically lists your “Compact Privilege” to avoid out-of-state denials.

Your 2026 Credentialing Strategy

To protect your practice this year, we recommend a three-step audit:

Sync Your NPPES and PECOS: Discrepancies between your NPI record and Medicare enrollment are now a top cause for 2026 claim holds.

Review State Compacts: If you practice across state lines via Psypact or the Counseling Compact, ensure your “Compact Privilege” is explicitly listed in your credentialing file with each payer.

Verify Taxonomy Codes: Ensure you are using the precise taxonomy (e.g., 101YM0800X for mental health) to avoid being misclassified as a “Medical” provider, which can trigger different (and often slower) credentialing rules.

For over 20 years, MedTrust Provider Advocates has been helping clients navigate the complicated and ever-changing credentialing process. Let us be your advocate and your guide.

As we look ahead to 2026, the world of mental health insurance credentialing continues to shift, bringing both opportunities and challenges for providers. From state-level program overhauls to ongoing federal initiatives, staying informed is key to ensuring your practice thrives and your clients receive the care they need.

Here’s a look at some of the significant developments and trends shaping mental health credentialing for the coming year:

Ohio’s MyCare Program Overhaul: A Precedent for Change?

One of the most impactful recent announcements, affecting many providers, especially those serving dual-eligible clients, comes from Ohio. Effective January 1, 2026, Aetna Better Health of Ohio and UnitedHealthcare Community Plan will no longer be part of the MyCare Ohio program. The Ohio Department of Medicaid (ODM) has awarded contracts to only Anthem Blue Cross and Blue Shield, Buckeye Health Plan, CareSource, and Molina Healthcare of Ohio for its “Next Generation MyCare Program.”

What does this mean?

• For Ohio Providers: If you currently contract with Aetna or UnitedHealthcare for MyCare Ohio members, you must now credential and contract with one of the four selected plans to continue serving these clients. This is a significant administrative undertaking that requires proactive engagement now to avoid service disruptions.
• For Ohio Members: Those enrolled with Aetna or UnitedHealthcare for MyCare will need to select a new plan.
• Broader Implications: This move by Ohio’s ODM could signal a trend. Other states may follow suit, re-evaluating their managed care contracts to streamline programs or enhance specific service delivery goals. This emphasizes the importance of diversified credentialing and staying updated on state-specific Medicaid and dual-eligible program changes.

The Push for Streamlined Federal Credentialing

While not always immediate, the push for more efficient federal credentialing continues to be a hot topic. The goal? To reduce administrative burden and get providers into networks faster, ultimately increasing access to care.

• PECOS Enhancements: Expect ongoing enhancements to the Provider Enrollment, Chain and Ownership System (PECOS) by CMS. The aim is to make the Medicare and Medicaid enrollment process more intuitive and reduce processing times. While these changes are iterative, they collectively contribute to a smoother experience over time.
• Standardization Initiatives: Discussions around standardizing credentialing requirements across federal programs, and potentially encouraging commercial payers to adopt similar models, are always in the background. While a complete overhaul is complex, any moves toward greater standardization are welcome news for mental health providers, who often juggle diverse payer requirements.

Telehealth Credentialing: Permanent Fixtures and Evolving Rules

The post-pandemic landscape has solidified telehealth’s role in mental healthcare, but the rules for credentialing are still evolving.

• Permanent Flexibilities: Many of the telehealth flexibilities for mental health services that emerged during the Public Health Emergency (PHE) have been made permanent or extended, particularly by CMS. This provides stability for providers offering remote care.
• Commercial Payer Alignment: For 2026, the focus will be on continued alignment from commercial payers. While most have embraced telehealth, providers must meticulously verify each payer’s specific requirements regarding:
  • Place of Service (POS) codes (e.g., POS 02 for telehealth, POS 10 for telehealth in the home).
  • Modifiers (e.g., -95).
  • State-specific regulations for interstate practice.
  • Supervision requirements for associate-level therapists practicing via telehealth.
• Digital Health Credentialing: The rise of digital mental health platforms and apps is creating new credentialing pathways. Expect more specific guidelines for providers working exclusively or primarily through these digital modalities, focusing on security, privacy, and quality assurance.

The Ongoing Battle Against Administrative Burden

The administrative burden of credentialing remains a significant challenge, especially for solo practitioners and small group practices.

• CAQH ProView is Still King: CAQH ProView remains the central hub for most commercial and some state Medicaid plans. Maintaining an accurate, up-to-date, and frequently attested CAQH profile (at least every 90-120 days) is non-negotiable for streamlining the recredentialing process.
• Credentialing Services: The trend of outsourcing credentialing to specialized services is likely to continue growing in 2026, as practices seek to offload this complex, time-consuming task to focus on client care.
• AI and Automation: While still in early stages, the integration of AI and automation into credentialing processes (for things like document verification, data extraction, and status tracking) will see continued development, promising long-term relief from manual tasks.

Looking Ahead

For mental health professionals, 2026 promises to be a year of adaptation and strategic planning in the credentialing arena. Changes like Ohio’s MyCare program highlight the need for vigilance regarding state-level reforms. Simultaneously, ongoing federal efforts and the evolving telehealth landscape underscore the importance of meticulous documentation and proactive engagement with payers.

The core message for 2026 is clear: stay informed, stay organized, and don’t underestimate the power of proactive credentialing management. Your ability to navigate these changes directly impacts your practice’s stability and your clients’ access to vital mental health services. Let MedTrust Provider Advocates be your compass to help you navigate these changes.

As the holidays approach, hospitals and clinics across the country fill with the spirit of giving, gratitude, and togetherness. While the holiday season is a time for celebration and reflection, it’s also a unique moment to recognize the unsung heroes of healthcare—credentialing professionals—whose diligent work ensures every provider is ready to deliver safe, high-quality care. This year let’s unwrap the ways healthcare credentialing embodies the true meaning of the season and brings joy to both staff and patients.

The Spirit of Giving and Service

The holiday season is rooted in traditions of generosity, compassion, and community. Credentialing teams like MedTrust Provider Advocates quietly serve by verifying qualifications, protecting patient safety, and supporting providers behind the scenes. Their commitment reflects the same spirit of giving that defines the holiday—ensuring every patient receives care from trusted, competent professionals.

Credentialing professionals, much like the figures of Christmas lore, work tirelessly to deliver peace of mind as their “gift” to hospitals, mental health providers, and patients. Their efforts make it possible for others to focus on healing and hope during a season that can be especially challenging for those in need.

Building Connections and Community

The holidays are about cherishing connections and expressing gratitude for those who make a difference in our lives. In the healthcare community, the holiday are a time when teams come together to celebrate successes, reflect on challenges, and show appreciation for each other’s dedication. Credentialing teams play a vital role in this collaborative environment, helping to build a foundation of trust and reliability that supports every department.

Many healthcare organizations find creative ways to spread cheer during the season, from decorating workspaces and organizing potlucks to participating in charitable drives that benefit patients and local families. These traditions foster a sense of unity and remind everyone of the shared mission to care for others.

Small Acts, Big Impact

Just as a simple gift can brighten someone’s day, small acts by credentialing professionals—like expediting a provider’s approval or resolving a last-minute issue—can have a profound impact on patient care and provider satisfaction. Their attention to detail and dedication ensure that the right people are in the right place, at the right time, especially during the busy holiday season.

Stories from hospitals highlight how the holiday spirit extends beyond patient care to the entire healthcare team. From “Santa” visits in the NICU to festive activities for staff and families, these moments of joy and gratitude are made possible by the seamless work of credentialing and support staff behind the scenes.

Reflecting on the Year and Looking Ahead

The holiday season is also a time to look back on the year, celebrate achievements, and prepare for the challenges ahead. Credentialing teams can take pride in their essential contributions, knowing that their work upholds the highest standards of care and safety. As we gather with loved ones or colleagues—whether in person or virtually—let’s remember to thank those who make healthcare possible, especially during the holidays.

MedTrust Provider Advocates wishes you a joyful holiday season filled with gratitude, connection, and the quiet gifts of service that make all the difference in healthcare.

Gratitude at the Heart of Quality Care

As Thanksgiving approaches, many of us pause to reflect on what we’re grateful for—family, friends, good food, and good health. In the world of healthcare, there’s another group that deserves our appreciation: the credentialing professionals who work tirelessly behind the scenes to ensure that every provider is qualified, compliant, and ready to deliver safe patient care.

This Thanksgiving, let’s take a moment to recognize the unsung heroes of healthcare credentialing and explore why their work is something we can all be thankful for.

The Unsung Heroes at the Credentialing Table

While most people think of doctors, nurses, and other providers when they picture healthcare, few realize the critical role credentialing teams play. Like the chefs preparing a Thanksgiving feast, credentialing specialists ensure that every ingredient—every provider’s education, training, licensure, and background—is thoroughly checked and verified before anyone takes a seat at the table.

The Recipe for Quality Care

Credentialing is the secret recipe that keeps healthcare organizations running smoothly. Just as a Thanksgiving meal requires careful planning and attention to detail, so does the credentialing process. Each step—application, verification, committee review, and approval—ensures that only the most qualified professionals are granted privileges to care for patients.

Without this process, the quality and safety of patient care could be at risk. That’s a recipe for disaster! So, let’s give thanks for the diligence and dedication of credentialing professionals who keep our healthcare system safe and strong.

Gratitude for Teamwork

Thanksgiving is all about coming together, and credentialing is no different. It takes collaboration between providers, administrators, HR, and credentialing specialists to gather documents, verify information, and meet deadlines. When everyone works together, the result is a seamless onboarding process and a strong, unified healthcare team.

Counting Our Blessings: The Benefits of Effective Credentialing

• Patient Safety: Proper credentialing protects patients by ensuring only qualified professionals provide care.
• Compliance: Staying up-to-date with regulatory requirements helps organizations avoid costly penalties.
• Provider Satisfaction: A smooth credentialing process helps new providers feel welcomed and supported.
• Organizational Reputation: Effective credentialing builds trust with patients, payers, and the community.

Sharing the Gratitude

This Thanksgiving, consider showing your appreciation to the credentialing team with a heartfelt thank-you note, a shout-out at your next staff meeting, or even a slice of pumpkin pie. Their work may be behind the scenes, but its impact is felt by everyone.

Final Thoughts: A Table Set for Success

As we gather around the Thanksgiving table, let’s remember the importance of healthcare credentialing in delivering safe, high-quality care. By giving thanks for the professionals who make it all possible, we celebrate the spirit of teamwork, diligence, and gratitude that defines both Thanksgiving and the healthcare community.

From the MedTrust credentialing family to yours, have a safe, happy, and healthy Thanksgiving!

Aetna Better Health of Ohio and UnitedHealthcare Community Plan are being removed from the MyCare Ohio program.

This change is happening as the Ohio Department of Medicaid (ODM) transitions to the “Next Generation MyCare Program.”

Here are the key details you need to know:

Effective Date of Change

• Both Aetna Better Health of Ohio and UnitedHealthcare Community Plan will no longer be MyCare Ohio plans effective January 1, 2026.

The Reason for the Change

• The Ohio Department of Medicaid (ODM) is reforming the dual-eligible program by launching the Next Generation MyCare Program beginning January 1, 2026.
• In November 2024, ODM announced the four managed care organizations (MCOs) that were awarded contracts to serve as the Next Generation MyCare plans:
  1. Anthem Blue Cross and Blue Shield
  2. Buckeye Health Plan (Currently in MyCare and will continue)
  3. CareSource (Currently in MyCare and will continue)
  4. Molina HealthCare of Ohio (Currently in MyCare and will continue)
• Aetna and UnitedHealthcare were not among the MCOs selected for this next generation of the program.

Impact on Providers

• Continuation of Claims Payment: Aetna and UnitedHealthcare are responsible for paying claims for services rendered through December 31, 2025. They will continue to process and pay claims for up to 365 days from the end of the year.
• New Contracts Needed: Providers who wish to continue serving MyCare members must ensure they are contracted and credentialed with the remaining Next Generation MyCare plans (Anthem, Buckeye, CareSource, and Molina).

Impact on Members

• No Loss of Coverage: Current MyCare Ohio members will not lose coverage due to this change.
• Action Required: Members currently enrolled with Aetna Better Health of Ohio or UnitedHealthcare Community Plan must select a new Next Generation MyCare plan for their coverage beginning January 1, 2026.
• Automatic Enrollment: If a member does not select a new plan during the open enrollment period (which is generally November 1–30), they will be automatically enrolled in one of the new Next Generation MyCare plans.

In summary, the removal of Aetna and UnitedHealthcare is part of Ohio’s statewide overhaul of its dual-eligible (Medicare/Medicaid) managed care program.

Navigating Delays and Challenges in Healthcare Administration

Government shutdowns are more than just headlines and political debates—they ripple through many aspects of American life, including the healthcare system. One vital area affected is insurance credentialing, a process crucial for providers seeking to participate in health plans and deliver care to patients. In this blog, we’ll explore how a government shutdown can disrupt insurance credentialing and what providers and administrators can do to prepare and respond.

How Government Shutdowns Affect Credentialing

During a government shutdown, non-essential federal agencies and staff may be furloughed or otherwise unable to perform their regular duties. Many components of insurance credentialing rely on government agencies, including:

• Medicare and Medicaid Enrollment: The Centers for Medicare & Medicaid Services (CMS) may experience staffing shortages or complete pauses in application processing, leading to delays for providers seeking to enroll or renew their credentials. CMS typically furloughs a portion of its staff during a shutdown. While Medicare and Medicaid claims payments are generally maintained because they are mandatory programs, administrative functions like provider enrollment (credentialing) are considered non-essential and slow down or stop entirely.
• This directly affects the processing of the CMS-855 applications submitted through PECOS (Provider Enrollment, Chain and Ownership System). New providers applying for a Medicare or Medicaid number may face extensive, indefinite delays before they can start billing.
• Background Checks: Credentialing often requires background checks processed by federal agencies. A shutdown can halt or slow these checks, stalling applications.
• State Medical Licensing Boards: While most state boards remain operational, those that depend on federal systems or data may also experience delays.
• Verification of Social Security Numbers and Citizenship: Some credentialing steps require validation through the Social Security Administration or other federal entities, which may be unavailable or backlogged during a shutdown.

Consequences for Providers and Patients

The direct consequence of these delays is that healthcare providers might not be able to see patients with certain insurance plans until credentialing is complete. This can result in:

• Loss of income for providers awaiting approval
• Reduced access to care for patients, especially in underserved areas
• Administrative bottlenecks for healthcare organizations

Strategies to Mitigate the Impact

While providers can’t prevent a government shutdown, there are steps that practices and organizations can take to minimize disruptions:

1. Start Early: Submit credentialing applications as soon as possible, especially if a shutdown appears likely.
2. Stay Informed: Monitor government announcements and professional association updates to anticipate potential delays.
3. Communicate Proactively: Keep patients and staff informed about potential impacts on appointment availability or coverage.
4. Maintain Accurate Records: Ensure all documents and licenses are up-to-date to avoid avoidable delays once processing resumes.

Looking Forward

Government shutdowns are disruptive, but understanding their effects on processes like insurance credentialing can help healthcare providers and organizations plan ahead. By remaining proactive and adaptable, the healthcare community can navigate these challenges and continue to provide essential care, even when government operations are temporarily on hold.