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Billing Terms Glossary

Credentialing Terms: Definitions for Therapists and Psychiatrists

These credentialing terms are defined in plain English for therapists and psychiatrists. Credentialing and enrollment terms describe how a clinician or group gets approved to bill a payer. These definitions cover CAQH, NPI, taxonomy, effective dates, and Medicare and Medicaid enrollment.

In this section

45 terms defined
Written for psychotherapists and psychiatrists
Source organization linked on every entry

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Associate Licensed Clinician

General (all payers)

Also called: pre-licensed clinician; associate-level therapist; intern billing

Definition: A clinician who has completed a degree but is not yet fully licensed and practices under supervision toward full licensure.
Why it matters: Many payers will not credential associates or require billing under a supervisor, which shapes revenue and staffing.
Illustrative example: A payer does not credential associates, so the group bills under a supervisor when policy allows.

Verify: payer- and state-specific.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentBehavioral Health Specific Terms

Attestation

General (all payers)

Also called: CAQH attestation; profile attestation

Definition: The provider's confirmation that the data in their credentialing profile is accurate and current. Payers use it to trigger and support credentialing decisions.
Why it matters: An expired attestation can freeze credentialing and put network status at risk.
Illustrative example: A therapist re-attests in CAQH ProView after updating a new practice address.

Reference source DataSpring (formerly CAQH)

Categories Credentialing & EnrollmentProvider Data Management Terms

Authorization to Access CAQH

General (all payers)

Also called: CAQH authorization; profile authorization

Definition: The provider's permission, set inside ProView, that lets a named payer view the provider's CAQH profile.
Why it matters: Without it, the payer sees a blank profile and the application stalls.
Illustrative example: A practice adds each payer's name to the 'Authorize' list in ProView.

Related terms CAQH ProView Attestation Credentialing

Reference source DataSpring (formerly CAQH)

Categories Credentialing & EnrollmentProvider Data Management Terms

CAQH ProView

General (all payers)

Also called: ProView; CAQH profile; CAQH credentialing application

Definition: CAQH's online system where providers enter credentialing and practice data once and authorize payers to view it.
Why it matters: An incomplete or unauthorized profile is a top cause of credentialing delays.
Illustrative example: A therapist adds licenses, malpractice coverage, and work history to ProView, then authorizes each payer.

Verify: CAQH requires periodic re-attestation; confirm the current interval at caqh.org.

Reference source DataSpring (formerly CAQH)

Categories Credentialing & EnrollmentProvider Data Management TermsEHR & Healthcare Technology Terms

Clinical Psychologist

General (all payers)

Also called: clinical psychology; PhD psychologist; PsyD; doctoral psychologist

Definition: A clinical psychologist is a licensed psychologist who provides assessment and treatment of mental health conditions, usually with a doctoral degree. The Society of Clinical Psychology, Division 12 of the American Psychological Association, is a professional home for the field.
Why it matters: Psychologists often bill psychotherapy and psychological testing codes. Payer credentialing and Medicare enrollment have specific rules for this license type.
Illustrative example: A psychologist bills 90837 for therapy and 96130 for a testing evaluation.

Verify: Requirements vary by state and payer.

Reference source Society of Clinical Psychology (Division 12, American Psychological Association) · CMS Medicare Learning Network (MLN)

Categories Credentialing & EnrollmentBehavioral Health Specific Terms

CMS-855

General (all payers)

Also called: CMS-855I; CMS-855B; CMS-855R; Medicare enrollment application

Definition: The family of Medicare enrollment application forms. Different versions cover individual practitioners, organizations, and reassignment.
Why it matters: Choosing the wrong form delays enrollment.
Illustrative example: An individual clinician files the CMS-855I to enroll in Medicare.

Verify: confirm current form versions at cms.gov.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentMedicare & Medicaid Terms

CMS-855I

Medicare

Also called: 855I; Medicare enrollment application individual practitioner; CMS 855I form

Definition: CMS-855I is the Medicare enrollment application for individual physicians and non-physician practitioners who want to enroll or change their enrollment information.
Why it matters: Errors or missing information delay enrollment. Many enroll or update through PECOS online. Use the correct form for the enrollment action.
Illustrative example: A newly licensed clinician completes the 855I in PECOS to enroll in Medicare.

Verify: Confirm the current form and process on CMS.gov.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentMedicare & Medicaid Terms Medicare

CMS-855R

Medicare

Also called: 855R; Medicare reassignment of benefits form; CMS 855R form

Definition: CMS-855R is the Medicare form used to reassign the right to receive Medicare payment from an individual practitioner to another eligible entity, such as a group practice.
Why it matters: A clinician joining a group usually needs a reassignment on file before the group can be paid for their services. Keep the group and the clinician's records aligned.
Illustrative example: A therapist joins a group, and both the therapist and the group complete an 855R so the group can bill for her Medicare services.

Verify: Confirm the current form and process on CMS.gov.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentMedicare & Medicaid Terms Medicare

Counseling Compact

General (all payers)

Also called: counseling licensure compact; compact privilege to practice; interstate counseling license

Definition: The Counseling Compact is an interstate agreement that lets licensed professional counselors who qualify be granted a privilege to practice in other member states. The ACA describes it as a mutual recognition model, similar to a driver's license. The ACA reported that 38 states and the District of Columbia had ratified it as of September 30, 2025.
Why it matters: It affects telehealth across state lines, but payers still credential, and each state may have its own rules for privileges. Check that the state where the patient sits is in the compact and that the privilege is active.
Illustrative example: A counselor licensed in one compact state applies for a privilege to see a client who lives in another compact state.

Time-sensitive: States are joining and privileges are rolling out. Confirm the current status at the compact commission website.

Reference source ACA, The Counseling Compact (9/30/2025) · American Counseling Association

Categories Credentialing & EnrollmentTelehealth Terms

Credentialing

General (all payers)

Also called: provider credentialing; insurance credentialing; payer credentialing

Definition: The process a payer uses to verify a clinician's license, education, training, work history, and standing before allowing that clinician to join its network.
Why it matters: A clinician who is not credentialed cannot bill in-network, and claims for services before the effective date are often denied or paid at out-of-network rates.
Illustrative example: A newly licensed therapist submits an application to a payer and waits for the credentialing decision before booking that payer's members as in-network.

Verify: turnaround times vary by payer; never quote a number of days.

Reference source NCQA · DataSpring (formerly CAQH)

Categories Credentialing & Enrollment

Credentialing Application Status

General (all payers)

Also called: application pending; pending credentialing

Definition: The stage of a payer's review, such as received, in process, pending committee, approved, or denied.
Why it matters: Tracking status prevents duplicate submissions and missed follow-ups.
Illustrative example: A payer portal shows 'pending committee' for a submitted file.

Reference source NCQA

Categories Credentialing & Enrollment

Credentialing Committee

General (all payers)

Also called: peer review committee; credentials committee

Definition: The panel of a payer or health plan that reviews completed applications and votes to approve or deny network participation.
Why it matters: The committee's meeting schedule can add weeks that the practice cannot speed up.
Illustrative example: A completed application waits for the payer's next scheduled committee review.

Reference source NCQA

Categories Credentialing & Enrollment

Credentialing Software

General (all payers)

Also called: credentialing platform; provider data management software

Definition: Software that stores provider documents, tracks expirations, and manages payer enrollment tasks.
Why it matters: Reduces missed expirations but does not replace payer decisions.
Illustrative example: A group uses software to alert them 90 days before a license expires.

Verify: vendor products and names change.

Reference source DataSpring (formerly CAQH)

Categories Credentialing & EnrollmentEHR & Healthcare Technology Terms

Credentialing Turnaround

General (all payers)

Also called: credentialing timeline

Definition: The elapsed time from a complete application to a payer's decision. It varies by payer, state, and file completeness.
Why it matters: Sets expectations for when a new clinician can see that payer's members in-network.
Illustrative example: Describe the steps of the process instead of quoting a number of days.

Verify: turnaround varies by payer; no number of days is stated here.

Reference source NCQA

Categories Credentialing & Enrollment

CredentialMyDoc

General (all payers)

Also called: CredentialMyDoc software

Definition: A vendor offering credentialing and provider enrollment tools. Naming a vendor here is not an endorsement or partnership.
Why it matters: Part of the credentialing technology landscape.
Illustrative example: A group evaluates credentialing software vendors.

Verify: confirm current product details at the vendor site.

Related terms Credentialing Software CAQH ProView

Reference source CredentialMyDoc

Categories Credentialing & EnrollmentEHR & Healthcare Technology Terms

DataSpring (formerly CAQH)

General (all payers)

Also called: CAQH; Council for Affordable Quality Healthcare; CAQH Solutions

Definition: DataSpring, formerly known as CAQH, is a nonprofit alliance of health plans and related organizations. Its ProView tool and CORE operating rules are widely used for provider data and administrative simplification.
Why it matters: Most commercial payers pull provider data from DataSpring (formerly CAQH), so an out-of-date profile delays credentialing.
Illustrative example: A payer says, 'We will pull your information from CAQH once you authorize us.'

Related terms CAQH ProView CAQH CORE Attestation

Reference source DataSpring (formerly CAQH)

Categories Credentialing & EnrollmentProvider Data Management Terms

DEA Registration

General (all payers)

Also called: DEA number; DEA license

Definition: A registration from the Drug Enforcement Administration that allows prescribers to prescribe controlled substances.
Why it matters: Payers and pharmacies verify it, and it is part of credentialing for prescribers.
Illustrative example: A psychiatrist's DEA registration is listed in the credentialing file.

Verify: confirm at the DEA.

Related terms EPCS Credentialing

Reference source HHS (U.S. Department of Health and Human Services)

Categories Credentialing & EnrollmentBehavioral Health Specific Terms

Delegated Credentialing

General (all payers)

Also called: delegation agreement

Definition: An arrangement in which a payer lets another organization, such as a large group or IPA, perform credentialing on its behalf under agreed standards.
Why it matters: It can shorten enrollment for clinicians inside a delegated group, but it requires audits and oversight.
Illustrative example: A large group with a delegation agreement credentials its own clinicians for a payer.

Related terms Credentialing NCQA Group Enrollment

Reference source NCQA

Categories Credentialing & EnrollmentContracting & Network Management

Effective Date

General (all payers)

Also called: network effective date; participation effective date

Definition: The date a clinician's in-network participation with a payer officially begins. Claims for earlier dates of service are usually not payable in-network.
Why it matters: It defines which sessions can be billed in-network and which cannot.
Illustrative example: A payer approves a therapist on March 10 with an effective date of April 1; March sessions cannot be billed in-network.

Verify: retroactive effective dates vary by payer and state.

Reference source NCQA

Categories Credentialing & EnrollmentContracting & Network Management

Enrollment Follow-Up Call

General (all payers)

Also called: Follow-Up Call; payer follow-up; credentialing status call

Definition: Contacting a payer to confirm receipt, request status, or resolve missing items on an application.
Why it matters: Documented follow-up calls prevent files from sitting idle.
Illustrative example: A specialist logs the date, rep name, and reference number of each payer call.

Reference source NCQA

Categories Credentialing & Enrollment

Group Enrollment

General (all payers)

Also called: group contract enrollment; group participation

Definition: Enrolling a group practice (its Type 2 NPI and tax ID) with a payer, then linking individual clinicians to that group.
Why it matters: Individual clinicians often cannot bill under the group until both the group and the linking are complete.
Illustrative example: A new therapist is added to the group's contract after the payer processes a roster update.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentContracting & Network Management

Initial Credentialing

General (all payers)

Also called: new provider credentialing; initial application

Definition: The first full credentialing review of a clinician by a payer, before the clinician's first in-network effective date.
Why it matters: It sets the effective date that decides which dates of service can be billed in-network.
Illustrative example: A psychiatrist joins a group and the group files initial applications with each payer.

Reference source NCQA

Categories Credentialing & Enrollment

Licensed Professional Counselor (LPC)

General (all payers)

Also called: LPC; LCPC; LPCC; LMHC; licensed clinical professional counselor; licensed mental health counselor

Definition: A licensed professional counselor is a master's-level or higher clinician licensed by a state to provide counseling and psychotherapy. The exact title differs by state, such as LPC, LCPC, LPCC, or LMHC.
Why it matters: Payers credential counselors by license type and have different rules for each. Medicare recognizes counselors who meet its mental health counselor definition.
Illustrative example: An LPC enrolls with commercial plans as a counselor and, if eligible, with Medicare as a mental health counselor.

Verify: Titles and requirements vary by state.

Reference source American Counseling Association · CMS Medicare Learning Network (MLN)

Categories Credentialing & EnrollmentBehavioral Health Specific Terms

Licensure Compact

General (all payers)

Also called: interstate compact; PSYPACT; Counseling Compact

Definition: An agreement among states that lets qualifying clinicians practice across participating states without a separate license in each. Examples include compacts for psychologists and counselors.
Why it matters: Affects which patients a clinician can treat by telehealth and which states a practice can serve.
Illustrative example: A psychologist uses an interstate practice authorization to treat a patient in another member state.

Verify: participating states and start dates change.

Reference source HHS (U.S. Department of Health and Human Services)

Categories Credentialing & EnrollmentTelehealth Terms

Linking a Provider to a Group

General (all payers)

Also called: provider linkage; reassignment of benefits

Definition: Associating an individual clinician's NPI with a group's billing NPI and tax ID at a payer, so claims pay to the group.
Why it matters: Missing linkage causes the claim to reject or pay to the wrong entity.
Illustrative example: A payer approves an individual but the group linkage is still pending; claims are held.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentContracting & Network Management

Malpractice Insurance (Professional Liability)

General (all payers)

Also called: professional liability insurance; malpractice coverage

Definition: Insurance covering claims of professional negligence. Payers require proof of coverage limits during credentialing.
Why it matters: An expired certificate can pause a credentialing file.
Illustrative example: The practice uploads a current certificate of insurance to the CAQH profile.

Related terms Credentialing CAQH ProView Attestation

Reference source NCQA

Categories Credentialing & Enrollment

Medicare Enrollment (PECOS)

General (all payers)

Also called: PECOS; Provider Enrollment, Chain and Ownership System; Medicare provider enrollment

Definition: The CMS system and process for enrolling in Medicare and maintaining enrollment records.
Why it matters: An unenrolled or outdated Medicare enrollment blocks payment and can cause claim denials.
Illustrative example: A newly licensed clinical social worker completes Medicare enrollment before billing Medicare.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentMedicare & Medicaid Terms

MedTrainer

General (all payers)

Also called: MedTrainer credentialing

Definition: A vendor offering credentialing, compliance, and training software. Naming a vendor here is not an endorsement or partnership.
Why it matters: Shows how credentialing and compliance tasks can be combined in one system.
Illustrative example: A clinic tracks license and training expirations in one platform.

Verify: confirm current product details at the vendor site.

Reference source MedTrainer

Categories Credentialing & EnrollmentEHR & Healthcare Technology Terms

Modio Health

General (all payers)

Also called: Modio; Modio credentialing software

Definition: A vendor of credentialing and provider enrollment software used by health care organizations. Naming a vendor here is not an endorsement or partnership.
Why it matters: Illustrates the category of credentialing platforms billing teams may encounter.
Illustrative example: An organization uses a credentialing platform to track licenses and payer applications.

Verify: confirm current product and ownership at the vendor site.

Related terms Credentialing Software CAQH ProView

Reference source Modio Health

Categories Credentialing & EnrollmentEHR & Healthcare Technology Terms

NCQA

General (all payers)

Also called: National Committee for Quality Assurance

Definition: A private nonprofit that sets quality standards, accredits health plans and credentialing operations, and publishes the HEDIS measures.
Why it matters: Many payers follow NCQA credentialing standards, which is why they require primary source verification.
Illustrative example: A health plan cites NCQA accreditation when explaining its credentialing steps.

Reference source NCQA

Categories Credentialing & EnrollmentQuality & Risk Adjustment Terms

Open Panel

General (all payers)

Also called: closed panel; panel status

Definition: A payer's status for a specialty or area: open panels accept new applicants, closed panels do not, often because the payer considers the network full.
Why it matters: A closed-panel rejection is a common reason new therapists cannot join a network.
Illustrative example: A payer tells a solo therapist its panel for that county is closed.

Reference source NCQA

Categories Credentialing & EnrollmentContracting & Network Management

Opt-Out (Medicare)

General (all payers)

Also called: Medicare opt-out; private contract with Medicare patient

Definition: A formal choice by certain practitioners to stop billing Medicare and instead contract privately with beneficiaries under specific rules.
Why it matters: Opting out has strict paperwork and duration rules; mistakes can jeopardize Medicare payment.
Illustrative example: A psychiatrist files an opt-out affidavit and then uses private contracts with Medicare patients.

Verify: confirm requirements with the MAC or counsel.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentMedicare & Medicaid Terms

Primary Source Verification (PSV)

General (all payers)

Also called: PSV; source verification

Definition: Confirming a credential directly with the organization that issued it, such as a state licensing board, instead of relying on a copy the clinician supplies.
Why it matters: Accrediting bodies expect PSV, and it is a common reason applications stall.
Illustrative example: The payer checks a psychologist's license status directly on the state board's website.

Reference source NCQA

Categories Credentialing & EnrollmentAudits & Compliance

Provider Enrollment Specialist

General (all payers)

Also called: credentialing specialist; enrollment coordinator

Definition: A staff role responsible for applications, follow-up, and maintaining payer enrollment records.
Why it matters: Provides the internal owner for credentialing deadlines.
Illustrative example: A credentialing specialist tracks every payer application in a spreadsheet.

Reference source DataSpring (formerly CAQH)

Categories Credentialing & Enrollment

Reassignment of Benefits (Medicare)

General (all payers)

Also called: CMS-855R; reassignment; reassigning Medicare payments

Definition: A Medicare enrollment action that lets an eligible provider assign the right to receive Medicare payment to a group or organization.
Why it matters: Without it, Medicare payment cannot go to the group.
Illustrative example: A group files enrollment paperwork so a psychologist's Medicare payments go to the group's account.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentMedicare & Medicaid Terms

Recredentialing

General (all payers)

Also called: re-credentialing; recredentialing cycle

Definition: The periodic review a payer repeats to confirm a network clinician still meets its standards. Many payers repeat it on a multi-year cycle set by the payer.
Why it matters: Missing a recredentialing request can lead to termination from the network and claim denials.
Illustrative example: A payer emails a recredentialing notice; the practice updates its profile and attests before the deadline.

Verify: cycle length is payer-specific.

Reference source NCQA

Categories Credentialing & Enrollment

Retroactive Effective Date

General (all payers)

Also called: retro effective date; backdated effective date

Definition: An effective date set earlier than the approval date. Some payers and some state laws allow it; many do not.
Why it matters: If allowed, it can recover earlier dates of service; if not, those sessions may be unbillable in-network.
Illustrative example: A state Medicaid program grants an effective date back to the application receipt date.

Verify: state- and payer-specific.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & Enrollment

Roster

General (all payers)

Also called: provider roster; roster submission

Definition: A file or list of clinicians in a group that the group sends to a payer to add, update, or remove providers.
Why it matters: Roster errors delay when a new clinician can bill.
Illustrative example: A group emails a roster update to add two new clinicians and remove one.

Reference source DataSpring (formerly CAQH)

Categories Credentialing & EnrollmentContracting & Network Management

Scope of Practice

General (all payers)

Also called: practice authority; independent practice authority

Definition: The services a licensed professional is legally allowed to provide, defined by state law and board rules.
Why it matters: Payers may deny services outside a clinician's scope.
Illustrative example: A state limits which diagnoses a counselor may make.

Verify: state-specific.

Reference source HHS (U.S. Department of Health and Human Services)

Categories Credentialing & EnrollmentBehavioral Health Specific Terms

State License

General (all payers)

Also called: professional license; state licensure

Definition: The authorization a state board issues that allows a clinician to practice a profession in that state.
Why it matters: Payers verify license status directly and deny claims for lapsed or wrong-state licensure.
Illustrative example: A therapist practicing via telehealth must be licensed where the patient is located.

Verify: rules vary by state and profession.

Reference source HHS (U.S. Department of Health and Human Services)

Categories Credentialing & Enrollment

State Medicaid Enrollment

General (all payers)

Also called: Medicaid provider enrollment; Medicaid ID

Definition: Enrolling a provider with a state's Medicaid program, and often separately with each Medicaid managed care plan.
Why it matters: Medicaid enrollment is state-specific and separate from Medicare and commercial credentialing.
Illustrative example: A therapist enrolls with the state Medicaid agency, then contracts with each managed care plan.

Verify: state-specific.

Reference source Medicaid.gov

Categories Credentialing & EnrollmentMedicare & Medicaid Terms

Supervising Provider

General (all payers)

Also called: supervising clinician; billing under supervision

Definition: A licensed clinician who oversees the services of a supervisee, and whose name or number some payers require on the claim.
Why it matters: Rules on billing supervisees vary widely by payer and state; getting them wrong can lead to takebacks.
Illustrative example: An associate therapist's claims list a licensed supervisor as the billing or supervising provider under one payer's policy.

Verify: payer- and state-specific.

Reference source CMS (Centers for Medicare & Medicaid Services)

Categories Credentialing & EnrollmentClaims Processing

The Joint Commission

General (all payers)

Also called: TJC; Joint Commission accreditation

Definition: A nonprofit that accredits hospitals and other health care organizations, including behavioral health programs.
Why it matters: Accreditation can be a payer or state requirement for certain program types.
Illustrative example: A residential program cites its Joint Commission accreditation to a payer.

Related terms NCQA URAC

Reference source The Joint Commission

Categories Credentialing & EnrollmentQuality & Risk Adjustment Terms

URAC

General (all payers)

Also called: URAC accreditation

Definition: An independent accrediting organization for health plans, utilization review, and other health care organizations.
Why it matters: Some payers and utilization-review vendors hold URAC accreditation, shaping their review standards.
Illustrative example: A utilization review vendor states it is URAC-accredited.

Reference source URAC

Categories Credentialing & EnrollmentQuality & Risk Adjustment Terms

Waitlist Request

General (all payers)

Also called: panel waitlist; network waitlist

Definition: A request to be considered if a payer's closed panel reopens or need changes.
Why it matters: Some payers keep waitlists; others reject outright.
Illustrative example: A therapist asks a payer to place the application on hold until the panel reopens.

Reference source NCQA

Categories Credentialing & Enrollment

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Credentialing Terms: Definitions for Therapists and Psychiatrists

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