Credentialing and Contracting

Credentialing and contracting are two important steps that a doula may need to complete when working with insurance companies or healthcare programs to receive reimbursement for services.

This article provides an overview of the fundamentals of working with insurance companies and other payers, along with key considerations to keep in mind as you expand into this area of your business. Processes can vary significantly depending on the company and state, so the information shared here is intended as a set of general guidelines. We encourage you to use this as a foundation to conduct further research tailored to your specific needs and circumstances.

Credentialing

Credentialing is the process by which an insurance company verifies a doula’s qualifications and eligibility to provide care. This ensures that the doula meets the necessary standards set by the insurance company and can be reimbursed for their services. The credentialing process typically involves:

1. Submitting Documentation: A doula will need to provide proof of their training, certifications, and experience. This could include copies of certification as a birth doula, postpartum doula, or any other relevant qualifications.
2. Verification: The insurance company will verify the doula's qualifications, including checking their certifications, education, and professional experience. They may also review the doula’s NPI (National Provider Identifier), licensing (if applicable), and any other professional background checks.
3. Approval: Once the insurance company verifies everything, the doula may be approved as an in-network provider, allowing them to bill the insurance company for reimbursement.

Credentialing is essential for doulas who wish to have their services covered by insurance, as it establishes them as a recognized healthcare provider with the insurance company.

Contracting

Contracting is the next step after credentialing. Once a doula has been credentialed by an insurance company, they may be offered a contract that outlines the terms and conditions under which the doula will work with that insurer. This contract typically includes:

1. Reimbursement Rates: The contract will specify how much the insurance company will reimburse the doula for specific services. It may also outline the payment structure and the time frame for receiving payments.
2. Terms of Service: The contract may include details on the types of services covered, any limits or exclusions, and how billing should be done (e.g., what codes to use for different services).
3. Obligations and Responsibilities: The contract will explain the responsibilities of both the doula and the insurance company, such as the need to adhere to billing guidelines and maintaining accurate records.
4. Network Participation: In some cases, the contract will specify whether the doula is considered an "in-network" or "out-of-network" provider. In-network providers typically receive higher reimbursement rates and are more likely to have services covered by the client’s insurance.

Having both credentialing and contracting in place allows doulas to work effectively with insurance companies and get reimbursed for their services, making it easier for clients to access and afford doula support. During this process, you can verify which doula services (e.g., prenatal visits, labor support, postpartum care) are covered. It is very important to do your own research and ensure you are familiar with the services that your payer offers.

Medicaid Programs

The process for credentialing and contracting with Medicaid varies by state, but generally involves the following steps:

• Understand State Medicaid Requirements: Each state has unique qualifications for doulas to enroll as Medicaid providers, such as certifications, training, or experience requirements. Check your state’s Medicaid website for details.
• Complete Required Training and Certification: Ensure you meet state-specific training and certification standards, which may include approved doula training programs, CPR certification, or continuing education.
• Apply for Medicaid Provider Enrollment: Submit an application through your state’s Medicaid program or its managed care organizations. This process typically requires proof of your credentials, identification, and potentially a background check.
• Contract with Managed Care Organizations (MCOs): If your state uses MCOs or MCPs (separate payers) for Medicaid, you may need to contract with them separately. Each MCO may have its own requirements and application process, and are often based on county or geographical area. Doulas must enter contracts with each MCP (Managed Care Plans) in their geographical area in order to serve clients who receive services through that MCP, and to receive reimbursement for doula services provided to MCP members.