Action Steps presented by www.cred2bill.com

As you are aware, credentialing and billing are deeply interdependent, and recent updates from the Centers for Medicare and Medicaid Services (federal CMS) effective July 1, 2025, have introduced changes that impact this relationship particularly with respect to billing types and Facility Setup. Your Credentialing Team must be knowledgeable about this setup to avoid denials.

All Critical Access Hospitals, Rural Health Clinics and any independent groups that have privilege only providers providing patient care at any of these entities should ask their Credentialing teams to review their affiliations and reassignments. Even though these changes impact revenue cycle, it’s your credentialing team that has to ensure all classifications and reassignments are accurately documented and where gaps are identified, remedy that situation.

Credentialing Team should be asking this question – How is your current billing system configurations is setup especially for Medicare.

Key Regulatory Changes & Action Steps your Credentialing Teams must take to avoid denials

1. Method II Billing for Critical Access Hospitals:

• Effective July 1, 2025, Critical Access Hospitals (CAHs) using Method II billing must ensure that every provider listed on UB-04 claims—including independent, contracted, or privilege-only providers—has formally reassigned billing rights to the hospital in PECOS. If reassignment is missing, CMS will deny the professional component with remark code N253: “Service not payable due to billing conflict”.
• The attending or rendering provider must be linked (reassigned) to the CAH’s Tax ID through PECOS. Both the provider and the CAH’s authorized official must sign any new reassignment requests as part of compliance.
• Credentialing teams must review all providers (including contracted/privilege-only providers) and validate that provider relationships are documented and reflected in PECOS via reassignment.
• Facility Setup: CAHs must clarify their billing type—Method II requires closer review and documentation of affiliations and reassignments for both employed and privilege-only practitioners.

2. Rural Health Clinic (RHC) Setup:

• Facility Billing (CMS-855A): If your RHC is enrolled and bills Medicare as a facility, a CMS-855A is required. Providers privileged at these sites must be linked to the facility’s Tax ID.
• RHC (Group/Supplier): If the RHC is structured as a group practice or supplier billing for professional services, CMS-855B is required.
• Exception: RHCs integrated under Method II CAH and receiving reassigned benefits do not require a separate CMS-855B form, but credentialing must confirm these billing arrangements.

3. Contracted/Privilege-Only Providers:

• Facilities billing for contracted (not directly employed) providers must submit a CMS-855A to link providers to the facility’s Tax ID/855 and document reassignment in PECOS. This will require surrogacy access or provider coordination to complete the process.
• Credentialing teams are now responsible for verifying and ensuring PECOS documentation and facilitating provider education if surrogacy is needed.

4. New Billing Edits & Claim Scrutiny:

• Starting July 1, 2025, CMS will systematically edit claims for reassignment presence and reject those missing proper affiliations, placing responsibility on credentialing to proactively address gaps.
• Audit readiness now requires written documentation of billing agreements and reassignments for all providers, not just employed staff.

Actionable Checklist for Credentialing Teams

• Confirm your CAH/RHC’s billing model: Are you using Method II for CAHs? Are RHCs set up under CMS-855A (facility) or CMS-855B (group/supplier)?
• Review all provider affiliations: Ensure every provider listed on claims has reassigned benefits in PECOS and is linked to your facility’s Tax ID.
• Validate billing for contracted/privilege-only providers: Submit necessary CMS-855A forms and coordinate surrogacy if your team needs to process reassignments.
• Check audit documentation: Verify that billing agreements and reassignment documentation are ready for audit or payer review.

Summary Table: Credentialing & Billing Compliance Post-July 2025

Facility Type	Billing Method	Required CMS Form	Reassignment in PECOS	Key Compliance Step
CAH (Method II)	Facility + Professional, UB-04	CMS-855A	Yes	Verify all UB-04 providers are reassigned
RHC (Facility)	Facility only	CMS-855A	Yes	Link privileged providers to facility’s Tax ID
RHC (Group/Supplier)	Professional (CMS-1500)	CMS-855B	Yes	Confirm setup, submit CMS-855B as needed
RHC under CAH Method II	Facility, with reassigned benefits	Included w/ CAH	Yes	Separate CMS-855B not required if reassignment present

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Immediate Steps

• Credentialing teams must work closely with billing departments and provider offices to review:
  • Provider lists on UB-04 claims.
  • PECOS affiliations and CMS-855A/855B submissions.
  • Documentation supporting billing relationships, including surrogacy arrangements with contracted groups.
  • Internal controls for ongoing updates as staff or privileged provider rosters change.

These changes—effective July 1, 2025—require a more integrated approach by credentialing teams to prevent denials and maintain compliance, especially regarding reassignment and documentation for all providers, including privilege-only and contracted clinicians.

https://www.cms.gov/files/document/mln006400-information-critical-access-hospitals.pdf

https://www.cms.gov/files/document/r13041otn.pdf

Cred2Bill is your Partner in – Provider Credentialing with Health Plans and Hospital Medical

Please contact us at www.Cred2bill.com or call 616-361-8292