Behavioral health credentialing — the telehealth billing rules that changed the reimbursement map

The public health emergency created telehealth billing for behavioral health as a temporary exception. What came after it is more complicated than either “all the waivers are permanent” or “everything reverted.” The reality is a fragmented landscape where some flexibilities are permanent under federal law, some were extended by subsequent legislation, some expired, and some vary by payer contract.

Practices billing behavioral health telehealth need to track which rules apply to which service, which payer, and which provider type. Credentialing is where this gets operationally complex.

What changed permanently under federal law

The Consolidated Appropriations Act of 2023 and the subsequent extension provisions made several telehealth flexibilities permanent for Medicare:

Mental health visit telehealth without an in-person requirement — but with conditions. Medicare now allows audio-visual behavioral health telehealth services permanently. The in-person requirement (which would have required an in-person visit within 6 months before and annually thereafter) was extended through the end of 2024 and suspended again by further legislation. As of current law, the in-person requirement for mental health telehealth is not in effect for Medicare, though this continues to be legislated year-to-year.

Audio-only behavioral health services. For patients who cannot access video telehealth due to lack of technology or capability, Medicare permanently allows audio-only billing for behavioral health services — but only if the provider has the technical capability to offer two-way audio-visual and the patient chooses audio-only. This distinction matters for billing and for the clinical documentation that supports the claim.

Federally Qualified Health Centers and Rural Health Clinics can bill telehealth permanently for mental health services. This is a significant change from pre-PHE rules, which largely excluded FQHCs and RHCs from telehealth billing.

Medicare Advantage plans are required to cover telehealth services at least as broadly as Medicare fee-for-service. In practice, MA plans vary in how they implement this — some are more generous, some add prior authorization requirements not present in fee-for-service.

What varies by state

State law governs parity requirements for commercial payer behavioral health telehealth, and the landscape varies:

Audio-only parity. More than 35 states have enacted telehealth parity laws that require commercial payers to cover audio-only behavioral health telehealth at the same rate as in-person services. The list of states changes as legislation moves. Operating in a state without audio-only parity means checking each commercial payer contract to determine whether audio-only behavioral health is a covered and reimbursed modality.

In-state licensure for telehealth. The provider must be licensed in the state where the patient is located at the time of service — not where the provider is located. For behavioral health practices billing across multiple states, each provider’s license portfolio needs to match the patient population’s state distribution. A therapist licensed only in California cannot bill a New York Medicaid patient via telehealth, regardless of where the therapist is sitting.

Interstate Compact participation (Counseling Compact, Psychology Interjurisdictional Compact). These compacts allow licensed providers to practice in member states without individual state licensure under certain conditions. The compacts are valuable for multi-state telehealth practices, but the credentialing implications are real — the provider still needs to comply with the compact’s registration requirements, and payer enrollment in compact states may require separate applications.

Credentialing requirements by modality

Behavioral health telehealth credentialing isn’t just a question of whether the provider is enrolled. Payers are increasingly differentiating by modality:

Synchronous audio-visual. Standard telehealth. Most payers treat this as equivalent to in-person for credentialing purposes — same application, same enrollment process, additional taxonomy codes or service locations added to the enrollment record.

Audio-only. Some payers require a separate attestation or modifier when billing audio-only. Credentialing teams need to confirm whether the payer recognizes audio-only as a distinct service requiring separate enrollment or whether it’s covered under the existing enrollment with a modifier at claim time.

Asynchronous (store-and-forward). Less common in behavioral health than in other specialties, but used in some digital therapy platforms. Some payers don’t cover asynchronous behavioral health at all. Those that do may require platform-specific credentialing or vendor-of-record attestations in addition to standard provider enrollment.

RPM and digital mental health tools. Remote patient monitoring for behavioral health — behavioral health integration codes like 99484, COCM codes 99492–99494, and psychiatric collaborative care codes — are billed differently from standard telehealth visits and require specific credentialing considerations, particularly when the billing provider is a PCP billing under collaborative care and the behavioral health consultant is the actual clinical contact.

The enrollment wrinkle that surprises practices

Behavioral health providers who shifted entirely to telehealth during the PHE and never returned to in-person practice have an enrollment record problem: their practice location on file with CMS and commercial payers may still reflect a physical address they vacated years ago.

When a payer re-credentials a behavioral health provider and pulls the enrollment record, a mismatch between the billed service location and the enrolled practice location creates a compliance flag. For telehealth, the “service location” on the claim is typically the patient’s home address or a telehealth modifier indicating an originating site — but the enrolled practice address still needs to be current and functional.

Practices operating fully virtual need to update their enrolled practice location to a current, valid address — typically a registered business address or virtual office address — and notify every payer of the update. This is a CMS enrollment update (via PECOS), a CAQH profile update, and a payer-specific notification for commercial plans. All three need to happen or the enrollment record stays inconsistent.

The provider type question

Not all behavioral health provider types have equivalent reimbursement rights in telehealth. Medicare covers telehealth for:

• Psychiatrists (MD/DO)
• Psychologists (PhD/PsyD) — certain services
• Licensed clinical social workers (LCSW)
• Licensed professional counselors (LPC) — added permanently by the CAA 2023
• Marriage and family therapists (MFT) — added permanently by the CAA 2023
• Certified nurse specialists in psychiatric and mental health care

LPCs and MFTs were excluded from Medicare telehealth prior to the CAA 2023. Practices that added these provider types expecting Medicare reimbursement under the PHE waivers needed to re-credential them once the permanent inclusion took effect — and some did not, leaving enrolled providers without current credentialing for the services they’re actually providing.

What to do this week

1. Audit your telehealth-active providers by state. Match each provider’s active state licenses to the states where your patient panel is located. Any mismatch is a billing compliance gap.
2. Check enrolled practice locations. If any provider went fully virtual, confirm that the address on file with CMS and commercial payers is current.
3. Verify LPC and MFT Medicare enrollment. If you added LPCs or MFTs after the CAA 2023, confirm they have completed Medicare enrollment under the new eligibility rules.
4. Review payer contracts for audio-only coverage. Don’t assume. Pull the behavioral health telehealth section of each major commercial contract and confirm what modalities are covered and at what rate.

Behavioral health telehealth credentialing has more moving parts than it looks. Talk to us if you’re expanding your telehealth footprint across states or provider types — we’ve done the enrollment work for the full range of these scenarios.

— Medical Credentialing Services