Payer Credentialing for Pharmacies: A Step-by-Step Guide to Getting Paid for Clinical Services

Your PBM contracts pay for dispensing fees. But what about clinical services? Those get paid through the patient's medical benefit: a whole new set of systems and payers. While it can seem intimidating to start, billing the medical benefit drives more revenue for your pharmacy per consult compared to dispensing.

As the need for clinical care at pharmacies continues to grow, there's no better time to get started with medical billing.

What is credentialing and why does it come first?

You can provide clinical services like vaccines, tests, and consults to patients in your pharmacy, but you won't get paid for any clinical services until you're in network with payers. Credentialing is the first step in getting set up to bill the medical benefit for clinical services and get paid for your patient care.

What is credentialing? It's a check with the payer plan that you (the pharmacist) are who you say you are and you're qualified to deliver patient care, through any relevant licenses, education, insurance, and work history.

There are a few terms that tend to get lumped together when talking about getting started with medical billing:

• Credentialing: done by the individual pharmacist; proves qualifications.
• Contracting: done by the pharmacy as a business; sets which services are covered and at what rate.
• Enrollment: registering with a government program (Medicaid, Medicare) so it can pay you. Medicaid and its managed care plans treat enrollment and credentialing as separate steps.

Today, we're going to walk you through everything you need to know about credentialing. Each payer has its own process and submission requirements, so it's important to plan for weeks to months in order to get your credentialing in place.

If you want to zoom out and understand what goes into getting set up for medical billing as a whole, check out our free resource here.

Before you start: decide what you'll bill and check your state's scope of practice

First things first: understanding what clinical services are in scope for pharmacists in your state. Since there are multiple payers you could get credentialed with, knowing what services you want to offer at your pharmacy's clinic will help you decide which payers to select.

A good place to start to understand what's in scope for pharmacies in your state is by visiting the National Association of Boards of Pharmacy website or connecting with your state's board of pharmacy, since regulations are constantly evolving. While evaluating services, make sure to note any particular protocol, collaborative-practice, supervision, documentation, or patient-age requirements for services in your state.

Some states require pharmacists to credential and contract with commercial payers, like UnitedHealthcare or Blue Cross Blue Shield. Over 40 state Medicaid programs pay pharmacists for providing care, although the scope of coverage varies by state.

Next, plan for how the services will be provided. Do you need a dedicated space to provide the clinical services? Who on the team will be responsible for which service-related tasks? Does your professional liability insurance cover the clinical services you plan to offer? You will need the certificate for the credentialing process.

Steps every pharmacy takes, whatever the payer

Get your National Provider Identifiers (NPIs) at the National Plan and Provider Enumeration System (NPPES). The NPI is the 10-digit standard unique health identifier for health care providers. You will need multiple NPIs: one for each pharmacist or practitioner delivering clinical services, and one for your pharmacy as a business. These are free to receive, and you can apply one of three ways:

• Online: https://nppes.cms.hhs.gov/login
• Paper application form: CMS.gov
• Authorize an employer or other trusted organization to obtain NPIs for you. Learn more at CMS.gov

Any changes to information submitted for your NPI must be reported within 30 days.

Choose your taxonomy codes. Taxonomy codes are unique 10-character codes that help to identify your classification and specialization as a health care provider. You use these codes when applying for your NPIs. Common codes include:

• 183500000X - Pharmacist
• 3336C0003X - Community/Retail Pharmacy
• Specialization code example: 1835C0206X - Cardiology Pharmacist, demonstrated specialized knowledge and skill in direct patient care, as designated by the Board of Pharmacy Specialties

See all taxonomy codes here.

File all credentialing documents in a folder for each practitioner. This will help to keep them organized and easy to update as needed.

• Contact info, social security number, individual NPI
• Pharmacist license number; DEA number if you have one
• Professional liability insurance certificate
• Practice location(s) and the pharmacy's Tax ID
• Education information (school, degree, dates) and training
• Work history, professional reference

Identify your target payers. Start with Medicaid managed care plans in your state and insurers you see the most frequently.

Getting credentialed with commercial, Medicare, and Medicaid payers

These three payer types require different credentialing applications. Once you decide which types of services and payers you'll bill for, you can get started with credentialing.

For commercial payers, you will need to get credentialed through DataSpring by CAQH. This is a national database that nearly all commercial payers use.

For Medicaid and Medicaid managed care plans, you'll start by confirming what your state Medicaid will pay for. Then, since each state runs its own system, you'll need to enroll with your state Medicaid agency. Once you enroll, you will need to get credentialed with each Medicaid managed care plan (MCO) in your state, although they often use CAQH.

For Medicare, there are three paths: Medicare Part B for vaccines and some services, "Incident-to" billing with a clinician partner, and Medicare Advantage plans, which are private. For Part B, you'll credential with CMS, by setting up CMS Identity & Access and then enroll in PECOS with Form CMS-855B. For "Incident-to" billing, the billing pharmacist must be an employee of the supervising physician, who is Medicare-recognized. For Medicare Advantage plans, credential them like a commercial plan.

If you're ready to get started with credentialing, download our step-by-step guide for getting credentialed with commercial, Medicare, and Medicaid payers! Check it out here.

After approval: stay credentialed and start billing

After you are officially credentialed, you'll move on to the maintenance phase of credentialing and be able to start billing for your clinical services.

Here's what you'll need to keep up with for the maintenance phase:

• Re-attest CAQH every 120 days, or payers may see your profile as out of date. Setting a recurring reminder in your calendar is a great way to keep track.
• Keep a credentialing tracker: which payer, date submitted, status, effective date, revalidation date. This will help you stay on top of your eligibility and enrollment.
• Communicate to patients their medical insurance may be billed for the services you're providing.
• Ensure proper clinical documentation: ensure proper clinical records are captured for each patient encounter, capture your time and effort.