Medicare and Medicaid Requirements Mental Health Providers Need Know About

Navigating the landscape of Medicare and Medicaid credentialing is a primary hurdle for modern

behavioral health practices. With recent updates in 2025 and 2026, the process has shifted toward

a "digital-first" model, emphasizing precision and automated compliance.

For therapists, counselors, and psychiatric providers, understanding these requirements is the

difference between a thriving practice and months of unpaid claims.

1. The Foundation: Medicare Credentialing for Behavioral Health

Medicare credentialing is managed at the federal level through the Centers for Medicare &

Medicaid Services (CMS). The primary tool you will use is PECOS 2.0 (Provider Enrollment,

Chain, and Ownership System), which was overhauled in late 2025 to streamline applications.

Key Requirements to Know:

• National Provider Identifier (NPI): You must have a Type 1 NPI (individual) and, if

you operate as an LLC or group, a Type 2 NPI (organization).

• Provider Transaction Access Number (PTAN): Once your application via PECOS is

approved, you are issued a PTAN. This is the number Medicare uses to identify you for

billing and claims processing.

• Exact Matching: One of the most common reasons for rejection in 2026 is a name

mismatch. Your legal business name must match exactly across your IRS CP-575,

NPPES, and PECOS profiles.

• Telehealth Updates: For 2026, the requirement for an in-person visit within six months

of a mental health telehealth service remains waived through December 31, 2027.

2. Medicaid Enrollment: A State-Specific Challenge

Unlike the federal uniformity of Medicare, Medicaid credentialing varies by state. However,

several universal trends have emerged in 2026 that behavioral health providers must incorporate:

• Background Checks & Fingerprinting: Depending on the state and enrollment type,

Medicaid may require high-risk screening, which can include fingerprinting and criminal

background checks.

• MCO vs. Fee-for-Service: Many states have moved behavioral health into Medicaid

Managed Care (MCO). This means you may need to credential with both the state

Medicaid agency and the specific MCO (e.g., UnitedHealthcare Community Plan or

Molina).

• Site Visits In some states, Medicaid may require a physical site visit as part of the

enrollment process—particularly for certain provider types or risk levels. This can apply

even to telehealth-based practices, depending on state requirements.

3. Mastering Behavioral Health Billing & Coding

Getting credentialed is only half the battle. To get paid, your medical billing for mental

health must reflect current 2026 coding standards.

Essential CPT Codes for 2026:

CPT

Code Description 2026 Requirements

90837 Psychotherapy, 60 min Must document 53+ minutes of face-to-face time.

90834 Psychotherapy, 45 min Standard for sessions lasting 38–52 minutes.

90791 Psychiatric Diagnostic Eval Commonly used for new patient intakes; not required in all cases depending on clinical and payer guidelines.

99484 General BHI Used for ongoing care management and coordination services

Critical Modifiers:

• -95: Used for synchronous audio-video telehealth sessions.

• -93: Used for synchronous audio-only telehealth, which is now a permanent fixture for

Medicare mental health services.

• GT (when applicable): Some Medicaid programs still require the GT modifier instead of

-95 for telehealth services.

4. Strategy for Behavioral Health Providers

To improve your practice's visibility and attract patients who use Medicare or Medicaid,

incorporate these keyword phrases into your website’s service pages and FAQs:

• “Psychiatrist accepting Medicare near me”

• “Mental health counselor accepting Medicaid in [Your City]”

• “Behavioral health billing requirements 2026”

• “Telehealth therapy for Medicare patients”

Pro Tip: Create a dedicated "Insurance & Pricing" page. Listing the specific Medicare and

Medicaid plans you accept provides a massive SEO boost because patients often search for their

insurance provider by name.

5. Staying Compliant: The "Ongoing" Phase

Credentialing is not "one and done." In 2026, CMS and state agencies have increased the frequency of revalidation.

• Medicare Revalidation: Usually occurs every 5 years.

• CAQH ProView: Most payers now require you to re-attest your information every 90

days. If not maintained, payers may delay processing, suspend updates, or flag your

participation status until your profile is current.

Quick Checklist for Your Practice:

• [ ] Update your CAQH profile quarterly.

• [ ] Monitor the OIG Exclusion List monthly to ensure no staff members are barred from

federal programs.

• [ ] Verify that your malpractice insurance limits meet the minimum state Medicaid

requirements (often $1M/$3M).

Medicare and Medicaid requirements for behavioral health providers can be complicated and

requires you stay updated on the latest changes. Sosa Practice Partners (SPP) can help you

navigate and understand these tricky requirements by handling all your Medicare and Medicaid

credentialing and billing needs. Typically considered one of the top five behavioral health billing

services, SPP not only provides billing and credentialing services, but also includes free practice

growth guidance, specifically tailored to each client’s goals. We pride ourselves on rapid 24

hours response, fast payments, personalized dedicated service, competitive transparent pricing,

and In-house HIPPA compliance processing standards.

Visit us at www.sosapartners.com and contact us to find out how we can help your practice.