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.

When you think of Halloween, you probably imagine costumes, candy, and a few friendly scares. But if you work in healthcare credentialing, you know that the credentialing process can sometimes feel just as tricky—and occasionally just as spooky! As October rolls around and the air fills with tales of haunted houses and ghostly ghouls, let’s take a lighthearted look at the parallels between healthcare credentialing and everyone’s favorite fright-filled holiday.

The Haunted Maze of Paperwork

Just like a haunted corn maze, the credentialing process can be full of twists, turns, and dead ends. Missing documents, outdated licenses, or incomplete applications can send you running in circles. The trick? Stay organized, keep a checklist, and don’t let the paperwork poltergeists catch you off guard!

The Disguises of Data

On Halloween, everyone loves to dress up and pretend to be someone else. In credentialing, it’s your job to make sure every provider is exactly who they say they are—no masks allowed! Verifying credentials, licenses, and work history is like unmasking the trick-or-treaters at your door. Only those with the right credentials get the treats (or, in this case, the privilege to provide care).

The Treats: A Smooth Credentialing Process

When everything goes right, credentialing can be a real treat. Providers are onboarded quickly, compliance is maintained, and patient safety is ensured. It’s the equivalent of finding a full-size candy bar in your trick-or-treat bag—a sweet reward for everyone involved.

The Spooky Surprises

Every Halloween party has its jump scares, and credentialing is no different. Maybe it’s a last-minute document request, an unexpected red flag in a background check, or a looming accreditation deadline. These surprises can send chills down any administrator’s spine. The key is to be prepared and have a plan for those “boo!” moments.

How to Avoid Credentialing Nightmares

• Stay organized: Use digital credentialing tools to keep everything in one place.
• Communicate clearly: Let providers know exactly what’s needed and when.
• Double-check everything: Don’t let a missing signature turn into a credentialing ghost story.
• Celebrate your wins: When the process goes smoothly, treat yourself (and your team) to a little Halloween candy!

Final Thoughts: No Tricks, Just Treats

Healthcare credentialing doesn’t have to be scary. With MedTrust Provider Advocates by your side, along with the right tools, a proactive approach, and a sense of humor, you can turn even the spookiest credentialing challenges into opportunities for improvement—and maybe even a little fun. So this Halloween, as you hand out candy and enjoy the festivities, remember: in the world of credentialing, MedTrust keeps the monsters at bay and ensures everyone gets the treats they deserve.

What It Means for Patients and Providers

Exploring the Impact of Policy Changes on Telemedicine Access

Introduction

Telehealth has revolutionized the way healthcare is delivered in the United States, especially in recent years. With the surge in demand during the COVID-19 pandemic, Medicare’s temporary coverage of telehealth services provided essential access for millions of seniors and people with disabilities. However, recent changes have resulted in Medicare  no longer covering telehealth, leaving many to wonder about the future of virtual care.

The Rise and Fall of Telehealth Coverage

When the pandemic began, the Centers for Medicare & Medicaid Services (CMS) quickly expanded telehealth coverage, allowing beneficiaries to receive a wide range of medical services from the safety of their homes. This policy shift was hailed as a critical step toward modernizing healthcare and reducing barriers to care for vulnerable populations.

However, these flexibilities were always intended as a temporary measure. As the public health emergency has ended, Medicare has phased out its expanded telehealth coverage. This means that, except for certain limited cases, Medicare beneficiaries can no longer use their insurance for virtual visits with their doctors.

What Does the Policy Change Mean?

The rollback has significant implications for both patients and healthcare providers:

• Patients lose convenience and access: Many seniors and people with disabilities who benefited from remote consultations now face increased challenges in accessing care, particularly those in rural areas or with mobility issues.
• Healthcare providers adjust operations: Clinics and practices that invested in telehealth infrastructure must now reconsider their offerings and workflows, which could result in financial strain or reduced service availability.
• Potential for increased in-person visits: As patients return to traditional office visits, there may be longer wait times, more crowded waiting rooms, and heightened exposure to communicable illnesses.
• Practitioners who provide behavioral and mental health via telehealth must now provide in-person visits within six months of the first telehealth visit and annually thereafter.

Why Did Medicare End Telehealth Coverage?

The decision to end expanded telehealth coverage is rooted in concerns over cost, fraud prevention, and the desire to return to pre-pandemic regulatory standards. Policymakers have cited the need for careful evaluation of telehealth’s effectiveness and appropriate use before establishing permanent coverage. Although some advocates argue for lasting policy changes, Congress and CMS have yet to enact comprehensive legislation to make telehealth a permanent part of Medicare benefits.

How Are Patients and Providers Responding?

The response from the healthcare community and Medicare beneficiaries has been mixed:

• Patient advocacy groups are lobbying for the reinstatement of telehealth benefits, emphasizing the importance of access and flexibility for older adults and those with chronic conditions.
• Healthcare organizations are urging federal agencies and lawmakers to reconsider, pointing to data that shows telehealth can improve outcomes and reduce costs in certain settings.
• Some providers are exploring alternative payment models or offering telehealth as an out-of-pocket service, though this may not be feasible for all patients.

What’s Next for Telehealth and Medicare?

The future of telehealth under Medicare remains uncertain. While the current coverage has ended, ongoing discussions in Congress and among healthcare stakeholders could pave the way for more permanent solutions. For now, Medicare beneficiaries should check with their healthcare providers about the availability of telehealth services and any associated costs.

As the healthcare landscape continues to evolve, it’s clear that virtual care has become an integral part of how Americans access medical services. Policymakers, providers, and patients alike must work together to ensure that progress in healthcare delivery is not lost and that access remains a priority for all.

Conclusion

The end of Medicare’s telehealth coverage marks a significant shift in healthcare policy, with broad implications for access, convenience, and innovation. While the debate continues, one thing is clear: the conversation about telehealth is far from over, and its role in the future of healthcare will depend on the actions of policymakers and the voices of those it serves.

Additional information on this issue:

https://telehealthresourcecenter.org/resources/the-telehealth-policy-cliff-preparing-for-october-1-2025/

https://www.cms.gov/files/document/telehealth-faq-04-09-25.pdf

https://www.bakerdonelson.com/medicare-telehealth-waivers-extended-through-september-2025

Optum and UnitedHealthcare

Key Requirements for Joining the UnitedHealthcare (including Optum) Network in Texas:

• Use of CAQH ProView: UnitedHealthcare, including Optum networks, requires physicians and many other healthcare professionals in Texas to complete and maintain their information in the Council for Affordable Quality Healthcare (CAQH) ProView database. You will need to grant UnitedHealthcare access to your CAQH profile. Ensure all sections are complete and up to date.  
• Texas License: A current and unrestricted license to practice in Texas is mandatory. The license must be in good standing with the relevant Texas licensing board.
• Professional Liability Insurance: You will need to provide proof of current professional liability insurance that meets UnitedHealthcare’s minimum requirements for your specialty and the state of Texas. Specific limits may apply.
• Work History: Expect to provide a detailed work history for the past five years, with explanations for any gaps longer than six months.  
• Education and Training: Verification of your medical education, residency, fellowships, and other relevant training will be required.
• Board Certification: Information on your board certifications, if applicable to your specialty, will be necessary.
• Hospital Privileges: For physicians, information regarding current hospital privileges or admitting arrangements with participating hospitals may be required.
• DEA/CDS Certificate: If you prescribe controlled substances, you’ll need to provide your current DEA (Drug Enforcement Administration) and Texas CDS (Controlled Dangerous Substances) certificates.
• NPI (National Provider Identifier): You must have a valid NPI to participate in the network.
• Tax Identification Number (TIN): Your TIN is required for contracting and payment purposes.
• W-9 Form: You’ll likely need to submit a completed W-9 form.
• Practice Information: Details about your practice location(s), including addresses, phone numbers, and contact information.
• Attestation: You will need to attest to the accuracy of the information provided in your application.
• Background Check: A criminal background check is typically part of the credentialing process.
• Completion of UnitedHealthcare Application: While CAQH is a primary source of information, you will also need to complete UnitedHealthcare’s specific network participation request through their provider portal, Provider Express.

Steps to Credential with UnitedHealthcare (including Optum) in Texas:

1. Register with CAQH: If you are not already registered, go to the CAQH ProView website (www.caqh.org) and complete your profile. Ensure all information is accurate and up to date. https://proview.caqh.org/Login/Index?ReturnUrl=%2f
2. Access Provider Express: Go to the UnitedHealthcare Provider Portal (https://www.uhcprovider.com/) and register for or log in with your One Healthcare ID.  
3. Complete the Network Participation Request: Navigate to the “Join Our Network” or credentialing section and complete the online application. You will need to provide your demographic information, specialty, service locations, and other required details.
4. Authorize CAQH Access: Within the UnitedHealthcare application, you will need to authorize UnitedHealthcare to access your CAQH ProView profile.  
5. Submit Supporting Documentation: Upload any required supporting documents, such as copies of your Texas license, DEA/CDS certificates, liability insurance face sheet, board certifications, and W-9 form, through the Provider Express portal or as instructed.
6. Primary Source Verification: UnitedHealthcare will verify your credentials with the primary sources (licensing boards, educational institutions, etc.).
7. Credentialing Committee Review: Your application and verified information will be reviewed by UnitedHealthcare’s credentialing committee.  
8. Notification: You will be notified in writing of the committee’s decision regarding your participation in the network.
9. Contracting: If approved for credentialing, you will then proceed with the contracting phase to finalize your agreement with UnitedHealthcare.

Important Points:

• Provider Express: This is the primary online portal for UnitedHealthcare providers to manage their information, including the credentialing process.
• Timelines: The credentialing process can take time, typically 45 calendar days or more from when a complete application and all required information are received. Primary source verification timelines depend on the responsiveness of the verifying entities.
• Recredentialing: UnitedHealthcare requires recredentialing every three years. Maintaining an up-to-date CAQH profile and attesting to its accuracy every 90 days can streamline this process.
• Specific Requirements: Requirements can vary slightly based on your provider type (physician, allied health professional, facility, etc.) and specialty. Always refer to the official UnitedHealthcare provider website and relevant provider manuals for the most accurate and detailed information.
• Optum Specifics: If you are specifically joining an Optum network (e.g., Optum Behavioral Health, Optum Physical Health), the initial steps will likely still involve CAQH and the UnitedHealthcare Provider Portal. However, there might be specific application pathways or additional requirements depending on the Optum line of business. It’s best to clarify this during the initial application process.

Recommendation:

The most reliable way to understand the exact and current credentialing requirements for Optum/UnitedHealthcare in Texas is to:

1. Visit the UnitedHealthcare Provider Portal (https://www.uhcprovider.com/).  
2. Navigate to the “Join Our Network” or “Credentialing” sections.
3. Review the specific requirements and steps outlined for your provider type and specialty in Texas.
4. Contact United Healthcare Provider Services directly if you have specific questions.

By following these steps, you can ensure you have the most accurate and up-to-date information for a successful credentialing process with Optum and UnitedHealthcare in Texas as of May 7, 2025.

Summary Table: Optum Credentialing Steps in Texas

National Wellness Month

National Wellness Month is a month-long observance held every August that encourages individuals to prioritize self-care, build healthy routines, and focus on their overall mental, physical, and emotional well-being. It was founded in 2018 by Live Love Spa to promote the idea that wellness is a lifestyle, not just a luxury.

How it’s Celebrated

Throughout the month, people are encouraged to take a holistic approach to their well-being. This can involve making small, manageable changes that lead to healthier habits. Common ways to celebrate include:

• Physical Wellness: Engaging in regular physical activity, trying new exercises like yoga or hiking, staying hydrated, and focusing on a nutritious diet.
• Mental and Emotional Wellness: Practicing mindfulness or meditation, taking breaks from screens, spending time in nature, and setting aside time for hobbies or relaxation.
• Social Wellness: Reconnecting with friends and family, and building strong support networks.

The August Reset: Why National Wellness Month Matters

August is here, and with it comes a dedicated time to focus on what often gets pushed to the back burner: your wellness. This isn’t just a marketing gimmick; National Wellness Month is a nationwide movement to remind us that taking care of ourselves isn’t a luxury—it’s a necessity. In our fast-paced lives, prioritizing health can feel like a chore, but this month offers a perfect opportunity to pause, reset, and build sustainable habits for a healthier, happier you.

What is Wellness, Anyway?

Wellness is a lot more than just hitting the gym or eating a salad. It’s a holistic concept that encompasses our physical, mental, emotional, and social health. Think of it like a four-legged chair; if one leg is weak, the whole thing is wobbly.

• Physical Wellness: This is what we usually think of first. It includes things like getting regular exercise, eating nutritious food, drinking enough water, and getting adequate sleep.
• Mental Wellness: This is about actively managing stress, practicing mindfulness, and being kind to yourself. It’s about taking a break from the endless scroll and letting your mind rest.
• Emotional Wellness: This involves recognizing and accepting your feelings, both good and bad, and developing healthy coping mechanisms. It’s about building emotional resilience.
• Social Wellness: A strong support network is critical to our well-being. This includes connecting with friends, family, and your community.

Simple Ways to Celebrate This Month

You don’t need a complete life overhaul to get started. Small, consistent steps can lead to significant changes. Here are a few ideas to get you going:

• Hydrate, Hydrate, Hydrate: The simplest change with a huge impact. Carry a water bottle with you and set a goal to refill it throughout the day.
• Take a Walk: A quick 15-minute walk outside can boost your mood, improve cardiovascular health, and give you a much-needed break from your desk.
• Try a Digital Detox: Challenge yourself to put your phone away for an hour before bed or for a few hours on the weekend.
• Start a Gratitude Journal: Writing down three things you’re grateful for each day can shift your mindset and reduce stress.
• Reconnect: Schedule a coffee date or a phone call with a friend you haven’t talked to in a while.
• Prioritize Sleep: Create a wind-down routine that helps you relax. This could be reading a book, taking a warm bath, or listening to a calming podcast.

National Wellness Month is a great excuse to finally book that annual check-up, find a new healthy recipe, or simply give yourself permission to rest without guilt. It’s a reminder that your health is your most valuable asset. So, this August, take the “I Choose Wellness” pledge and make a promise to prioritize you.

Blue Cross Blue Shield of Texas (BCBSTX)

General Requirements:

• Provider Record ID: You’ll generally need a valid BCBSTX Provider Record ID for claim payment. This is usually obtained through an initial enrollment process.
• Signed Agreement: A current, signed BCBSTX contract or agreement is required.  
• CAQH Provider Data Portal (f.k.a ProView): BCBSTX mandates the use of the Council for Affordable Quality Healthcare (CAQH) ProView database for initial credentialing and recredentialing for physicians and professional providers. Complete the online application with “global” or “plan specific” authorization granted to BCBSTX. Failure to finalize your CAQH application within 45 days can lead to discontinuation of the process.
• Texas License: A valid, unrestricted license to practice in the state of Texas, in good standing with the relevant Texas Licensing Boards, is essential.
• Professional Liability Insurance: You’ll need current professional liability insurance coverage with minimum limits. For Texas providers, the minimum requirement has been $100,000 per occurrence and $300,000 in aggregate (this was updated from a previous $200,000/$600,000 requirement). Specific ancillary providers may have different liability coverage requirements (e.g., Home Health Agencies may require $500,000/$1,000,000).  
• Work History: Initial credentialing often requires a work history of the past five years with no gaps greater than six months, or explanations for any such gaps.
• Hospital Affiliations (MDs/DOs): Information on admitting arrangements and hospital privileges may be required. A Facility Coverage Letter might be accepted in lieu of privileges in some cases.
• DEA/CDS Certificate: If applicable to your practice, a current DEA (Drug Enforcement Administration) or CDS (Controlled Dangerous Substances) certificate for each state where services are provided may be necessary.  
• Board Certification: Information on board certifications, if applicable to your specialty.
• General Information: Basic personal details like name, date of birth, social security number (last four digits or NPI), and contact information are required.  
• Practice Location Information: Details of your primary practice location(s), including address, phone, fax, email, and Tax Identification Number (TIN).
• Attestation and Release: You’ll need to sign and date an attestation confirming the accuracy of the information provided and authorize BCBSTX to verify your credentials.

Specific Requirements for Different Provider Types:

• Physicians and Professional Providers: Primarily use CAQH ProView for initial credentialing and recredentialing. Those not listed in CAQH’s approved provider types may need to complete the Texas Standardized Credentialing Application from the Texas Department of Insurance (TDI) website.  
• Hospitals, Facilities, and Allied Providers: These entities also undergo a credentialing process. They need to complete the appropriate enrollment form based on their facility type and provide the required documentation. Facilities can often submit credentialing applications through Availity™. Recredentialing is typically required every three years.  
• Ancillary Providers: Have a specific credentialing and contracting process. They often need to first obtain a Provider Record ID by submitting an Ancillary Provider Record Request Form. Following this, they complete a Credentialing/Recredentialing Ancillary/Hospital Provider Questionnaire and submit it with required documentation (e.g., licenses, liability insurance, accreditation if applicable).
• Durable Medical Equipment (DME) Suppliers and other specialties: Have specific checklists outlining required licenses, insurance, and accreditations.

Key Steps in the Credentialing Process:

1. Obtain a Provider Record ID:

https://www.bcbstx.com/provider/network/network/provider-onboarding-process

1. Complete the CAQH Provider Data Portal application:

https://proview.caqh.org/Login/Index?ReturnUrl=%2f

1. Provide all required documentation, such as licenses, insurance certificates, and other supporting materials.
2. Authorize BCBSTX to access your CAQH data (if applicable).
3. Attest to the accuracy of your information and sign the required forms.
4. Submit the completed application and documentation to BCBSTX.
5. BCBSTX will review the application and verify your credentials through primary sources. This review can take approximately 8-10 calendar days once the CAQH application is complete.  
6. You may be required to undergo a site review (for facilities).
7. BCBSTX will notify you of the credentialing decision. Approval is required before you can participate in their networks.

Recredentialing:

• BCBSTX requires recredentialing of network providers every three years.
• Physicians and professional providers will use CAQH ProView for recredentialing, needing to review and attest to their data.  
• Hospitals, facilities, and allied providers use a specific Credentialing and Recredentialing Facility and Allied Provider Form.

Important Considerations:

• Timeliness: Completing the CAQH application within 14 days of submitting your enrollment form is often recommended. Failure to finalize it within 45 days can lead to discontinuation.  
• Accuracy: Ensure all information provided is accurate and complete to avoid delays. Incomplete or duplicate applications can result in delays.  
• Updates: You are responsible for informing BCBSTX of any changes to your practice information (demographics, etc.) in a timely manner, typically within 30-45 days of the change, often through the CAQH portal.  
• Provider Manuals: Refer to the BCBSTX Provider Manuals for detailed policies, procedures, and requirements. There are specific manuals for different networks (e.g., PPO, Medicaid STAR/CHIP).  
• Credentialing Status Checker: BCBSTX often provides an online tool to check the status of your credentialing process using your NPI or license number.

Summary Table: BCBS Credentialing Steps in Texas

Core Requirements for Joining the Aetna Network in Texas:

• CAQH ProView: Aetna mandates the use of the Council for Affordable Quality Healthcare (CAQH) ProView database for healthcare credentialing and recredentialing of healthcare professionals. You must complete your online profile and authorize Aetna to access this information. Ensure your CAQH profile is accurate and up-to-date.  
• Texas License: A current, valid, and unrestricted license to practice in the state of Texas is required. The license must be in good standing with the relevant Texas licensing board.
• Professional Liability Insurance: You need to have current professional liability coverage that meets Aetna’s specific requirements for your specialty and the state of Texas. You will need to provide proof of this coverage.  
• Education and Training: Verification of your completed medical education, residency, fellowships, and any other relevant training is necessary.  
• Board Certification: Information about your board certifications, if applicable to your specialty, will be required and verified with the primary source.
• Work History: You will likely need to provide a detailed work history for the past five years, explaining any gaps longer than six months.  
• Hospital Privileges (for applicable providers): Information regarding your current hospital privileges or admitting arrangements at participating hospitals may be required.
• DEA and Texas CDS Certificates (if applicable): If you prescribe controlled substances, you must provide your current Drug Enforcement Administration (DEA) certificate and Texas Controlled Dangerous Substances (CDS) certificate.
• National Provider Identifier (NPI): A valid NPI is mandatory for participation.
• Tax Identification Number (TIN) and W-9: You will need to provide your TIN for contracting and payment purposes and submit a completed W-9 form.  
• Practice Information: Details about your practice locations, including addresses, phone numbers, and contact information, are required.
• Attestation: You will need to attest to the accuracy of the information you provide during the credentialing process.
• Background Checks: Aetna typically conducts background checks as part of the credentialing process.  

Steps to Credential with Aetna in Texas:

1. Request Participation: Initiate the process by completing the online Request for Participation form on the Aetna website for your specific provider type. Use the same form for Medical and Behavioral Health. https://extaz-oci.aetna.com/pocui/join-the-aetna-network
2. Aetna Review: Aetna will evaluate the need for providers in your service area. If there is a need and they intend to proceed with a contract, you will be notified within approximately 45 days.  
3. CAQH Registration and Authorization: Aetna uses CAQH as their primary source for credentialing data. If you are not already registered with CAQH ProView, you will need to do so. Once registered, ensure your profile is complete and authorize Aetna to access your information by specifically adding Aetna as an authorized plan in your CAQH profile.  https://proview.caqh.org/Login/Index?ReturnUrl=%2f
4. Credentialing Process: Aetna will obtain your information from CAQH and begin the credentialing process, which involves verifying your qualifications with primary sources.
5. Contracting: Once the credentialing process is complete and approved, your contract will be finalized, and you will receive welcome materials.  

Key Considerations:

• CAQH is Central: Ensure your CAQH profile is thorough, accurate, and you have granted Aetna access.
• Separate Contracting and Credentialing: Keep in mind that credentialing and contracting are separate processes, and both must be completed before you are considered in-network.  
• Timeliness: Respond promptly to any requests for information from Aetna or CAQH to avoid delays.  
• Accuracy: Ensure all information provided is accurate and verified. You have the right to correct any information obtained during the credentialing process by working directly with the reporting entities.  
• Recredentialing: Aetna requires recredentialing every three years in most states, requiring the same level of scrutiny as the initial process.  
• Provider Manuals: Refer to the Aetna Provider Manuals for detailed policies and procedures.  
• Contact Aetna: For specific questions about your application status or requirements, contact Aetna’s Credentialing Customer Service at 1-800-353-1232 (for medical and behavioral health) or 1-800-451-7715 (for dental).  

Summary Table: Aetna Credentialing Steps in Texas

Medicare (Novitas Solutions)

Core Requirements and Processes:

1. National Provider Identifier (NPI): You must have a valid NPI. You can apply for one through the National Plan and Provider Enumeration System (NPPES) website.  
2. Medicare Enrollment Application: You need to complete the appropriate Medicare enrollment application form https://www.cms.gov/medicare/forms-notices/cms-forms-list. The most common forms are:  
   • CMS-855I: For physicians and non-physician practitioners.  
   • CMS-855B: For clinics, group practices, and other suppliers (e.g., ambulance companies, Independent Diagnostic Testing Facilities – IDTFs).  
   • CMS-855A: For institutional providers (e.g., hospitals, Skilled Nursing Facilities – SNFs).  
   • CMS-855O: For ordering and certifying physicians and other eligible professionals who do not bill Medicare for their services.  

You can complete these applications either:

1. • Online via PECOS (Provider Enrollment, Chain and Ownership System): This is the preferred and generally faster method. You’ll need an Identity & Access Management (I&A) System user account to access PECOS.  

https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

• • Paper Application: Download the relevant CMS-855 form from the CMS website or the Novitas Solutions website, complete it, and submit it with all required supporting documentation. You can upload the completed paper application and supporting documents through the Provider Enrollment Gateway on the Novitas Solutions website or mail them directly to Novitas Solutions.  

3. Supporting Documentation: You must submit various documents along with your enrollment application, which may include:

• • Texas State License: A copy of your current and unrestricted Texas professional license.
  • DEA and Texas CDS Certificates (if applicable): Copies of your valid Drug Enforcement Administration (DEA) and Texas Controlled Dangerous Substances (CDS) certificates if you prescribe controlled substances.
  • Professional Liability Insurance: Proof of current coverage meeting Medicare requirements.
  • Board Certifications: Copies of relevant board certifications.
  • Education and Training: Documentation of your medical or professional education and training (e.g., diplomas, residency certificates).  
  • Tax Identification Number (TIN) and Legal Business Name Verification: IRS documentation (e.g., CP575) confirming your TIN and legal business name.  
  • Electronic Funds Transfer (EFT) Information: Completed CMS-588 form with a voided check or bank letter.  
  • Medicare Participation Agreement (CMS-460): Required for initial enrollment or reactivation if you want to be a participating provider.  
  • Adverse Legal Action Documentation (if applicable): Copies of any final adverse legal action documentation and resolutions.  
  • Business Licenses: Federal, state, and/or local business licenses, certifications, or registrations required to operate your healthcare facility.
  • For Organizations: Corporate documents, ownership information, etc.

4. Practice Location Information: You must provide the physical address(es) where you render services to Medicare beneficiaries. P.O. boxes, commercial mailboxes, or drop boxes are not acceptable as practice locations.  

5. Reassignment of Benefits (if applicable): If you plan to reassign your Medicare benefits to a group or organization, you must complete the relevant sections of the CMS-855I or CMS-855B form and provide information about the entity receiving the reassignment.

6. Attestation and Signature: You must sign and date the application (handwritten or eligible digital signature). The individual practitioner cannot delegate the authority to sign their own enrollment application.

7. Payment of Application Fee (if applicable): Certain provider and supplier types may be required to pay an application fee. You can pay this fee online through PECOS or the CMS Paper Application portal.  

Key Considerations:

• PECOS is Encouraged: CMS and Novitas Solutions strongly encourage using PECOS for enrollment as it can expedite the process.  
• Accuracy is Crucial: Ensure all information provided is accurate and complete to avoid delays or denials.
• Timeliness of Updates: You must report any changes to your enrollment information (e.g., change of address, ownership, adverse legal actions) to Novitas Solutions within specific timeframes (typically 30-90 days). This can be done through PECOS if you enrolled online or by submitting a new application or relevant updates if you used a paper application.  
• Revalidation: Medicare providers must revalidate their enrollment periodically (usually every five years, but potentially more frequently based on risk). Novitas Solutions will notify you when it’s time to revalidate.  
• State Licensure: Maintaining a current and valid Texas license is an ongoing requirement for Medicare participation.
• Provider Enrollment Gateway: This tool on the Novitas Solutions website allows you to upload paper applications, submit responses to development requests, and check the status of applications submitted through the gateway.  
• Medicare Learning Network (MLN): CMS offers various educational resources through the MLN to help providers understand Medicare enrollment requirements.

Summary Table: Medicare (Novitas Solutions) Credentialing Steps in Texas

Providers must enroll through the Texas Medicaid & Healthcare Partnership (TMHP) using its Provider Enrollment and Management System (PEMS). TMHP is the single source for medical provider credentialing services and enrollment, re-enrollment, revalidation, change of ownership, and maintenance requests. While TMHP handles the enrollment process for Texas Medicaid, it’s important to understand that credentialing for participation in Medicaid Managed Care Organizations (MCOs) and Dental Maintenance Organizations (DMOs) has specific considerations.

Below is a breakdown of the requirements and processes.

Artificial Intelligence (AI) is significantly impacting healthcare credentialing, moving it from a traditionally cumbersome and manual process to a more efficient, accurate, and secure one. Here’s a breakdown of AI’s role: