Medicaid Credentialing & MCO Plans: What You Need to Know

Medicaid Credentialing & MCO Plans: What You Need to Know

This blog post dives into the complexities of Medicaid credentialing, specifically focusing on the role of Managed Care Organizations (MCOs).

MCOs and Medicaid:

Medicaid, a government-funded health insurance program for low-income individuals, has seen an increasing adoption of MCO plans. These plans are offered by private insurance companies that manage Medicaid benefits and delivery. While you might be contracted with a commercial insurance company for Medicaid and Medicare, that doesn't automatically grant you access to their MCO plans.

Contracting and Credentialing:

It's crucial to understand that contracting and credentialing for MCO plans are separate processes from standard Medicaid and Medicare. You need to be credentialed with the base Medicaid program of your state before being considered for MCO plans. This applies to Medicare Advantage plans as well.

Example:

Let's say you have a contract with United Healthcare for commercial and Medicare plans. They also offer a Medicaid MCO plan called Community Care. If you're not contracted with the state's Medicaid program, you cannot bill Community Care patients. You'll first need to get credentialed with the state's Medicaid plan before applying for the MCO plan.

MCO Nuances:

MCOs can have specific requirements and application processes that differ from state Medicaid programs. They might have limitations on the counties they serve, requiring you to be in a specific location to contract with them.

Tips:

• Check your state's Medicaid website:?They often have maps showing the distribution of MCOs in different counties.
• Don't assume:?Just because you're contracted with a commercial insurance company for Medicaid/Medicare doesn't mean you're automatically in their MCO plans.
• Start with the base plan:?Get credentialed with your state's Medicaid program before applying for MCO plans.
• Be proactive:?Apply for MCO plans early to avoid delays in accepting patients.

Remember: This blog post is for informational purposes only and should not be substituted for professional advice. Always consult with a healthcare attorney or consultant for specific guidance on Medicaid credentialing and MCO contracting.

I hope this blog post provides a helpful overview of Medicaid credentialing and MCO plans. If you have any further questions, please leave them in the comments below.