Billing Tips for Non-Credentialed Providers


When a new or established provider has not been credentialed by an insurance company, it is believed to be the most common situation. This usually happens when a provider is employed straight out of residency or from another practice (in- or out-of-state). The query is also raised when a practice has merged (needing a new tax ID for that practice) or has added a new practice location.

The credentialing providers has become a specialty unto its own, needing information of the application procedures for the national provider identifier (NPI), Medicaid, Medicare, and commercial insurance companies. For providers to be credentialed in your practice, each and every step must be taken carefully. Nearly all of these application procedures might be undertaken online (except for few of the smaller payers), but they yet are time-consuming and need advance planning.

Offices few times consider that they can bill non-credentialed provider services under a credentialed provider’s NPI until the new provider is credentialed. But it would be unsuitable and would lead to audit recoupment and potential investigation.

Under the care-rendering provider’s NPI, all services must be billed. The mere exception would be when 1 provider is replacing or substituting another provider and a locum tenens or reciprocal billing arrangement has been developed between the original and replacement providers.

Each provider practicing at the location must be credentialed under the entity’s new name when a practice has merged and gains a new tax ID, if applicable, and new tax ID. Furthermore, credentialing is needed for each provider rendering services at a latest practice location.

A provider must be credentialed to be capable to bill for services he/she has rendered for each of these situations.


Certain NPPs are not recognized by few commercial insurance carriers to be credentialed. Incident-to billing (billing under a doctor’s NPI) can be utilized merely when all incident-to guidelines have been met during these situations.

The CMS (Centers for Medicare and Medicaid Services) established incident-to guidelines, and several commercial insurance carriers identify them as well. Because several carrier guidelines have altered and changed, check with each individual payer before billing incident-to for your NPPs, even if you’ve billed this way in the past. Incident-to requirements are very specific:

  • The services are an important, although incidental, part of the professional service of physicians.
  • The services are of a type normally furnished in offices or clinics of the physicians.
  • The services are furnished under the direct personal supervision of doctor and are furnished by the physician or by an individual who is a worker or independent contractor of the doctor. Straight supervision doesn’t need the presence of physician in the similar room, but the doctor must be available in the similar office suite and instantly available.
  • The services usually are rendered without charge or included in the bill of doctors.
  • The initial service and subsequent services of a frequency must be performed by the physician that depicts his/her active involvement in the management of the course of treatment.
  • The doctor or other provider under whose name and number the bill is submitted must be the individual present in the office suite when the service is given.


It is believed to be a very usual practice for doctors to retain substitute physicians to take over their expert practices when they are not present for any reason, like due to illness, pregnancy, or vacation.

The regular doctor can bill and get payment for the services of substitute physician after the assignment is accepted as though the regular doctor performed them. When the original physician has left the practice and is not able to give services, Locum tenens billing also can apply. Although, the substitute doctor must be credentialed in locum tenens situations. This is a Medicare rule, but several commercial insurance carriers have accepted and adopted it, so check with your individual payers before billing.

Don’t forget that this rule implements to physicians and might not be utilized for NPPs. There is a limit of sixty days for each locum physician, counted from the 1st day the locum doctor sees a sufferer, and it involves days that the locum doctor doesn’t see sufferers (the locum’s days off). You no longer might bill for that locum physician after the sixty days. If services still are required after that, then the practice must search a different locum doctor.

Under the NPI of the doctor who is not there, services rendered by the locum physician are billed, with the Q6 modifier appended to each CPT code on the claim. If the locum tenens renders postoperative care in the global period, although, it doesn’t require being recognized on the claim form as substitute services.

The office must keep a list of sufferers seen by the locum doctor (involving the locum physician’s NPI), and it must be made present to a carrier on request. The locum physician are paid by the regular physicians on a per-diem or similar fee-for-time basis. The identification of the substitute doctor significantly is for purposes of giving an audit trail to determine that the services were furnished, not for purposes of the payment or the limiting charge. Also, notices of non-coverage are to be provided in the name of the regular physician.

Note: You cannot use locum tenens billing when you’re adding a doctor who hasn’t been credentialed.


A provider can get payment for the services of substitute doctor in a second way are through a reciprocal billing arrangement.

If the regular physician manages a substitute doctor to furnish services on an occasional reciprocal basis, payments can be issued. Reciprocal billing arrangements follow the similar rules as locum tenens arrangements, except that modifier Q5 is appended to each CPT code submitted.

Normally, reciprocal billing arrangements don’t apply to physicians in the similar medical group where claims are filed in the name of the group. On claims filed or submitted by the group, the group doctor who really performed the service must be recognized, with 1 exception: When a group member gives services on behalf of another group member who is the designated attending physician for a hospice sufferers, the designated attending doctor might utilize the Q5 modifier to bill for services regarded to the terminal illness of hospice patient that were performed by another group member.

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