Credentialing & Billing
Credentialing with medical insurance carriers, payor enrollment, and contract review for Tennessee pharmacies and pharmacists, handled by a former deputy general counsel at the Department of Health and included in the Growth membership.
Eleven years inside Tennessee healthcare regulation, including as deputy general counsel at the Department of Health.
Licensed in Tennessee, with federal practice before the DEA, FDA, and HHS nationwide.
The healthcare division of Litson PLLC, ready if a matter reaches court.
How we approach it
Most pharmacies are paid almost entirely through billing pharmacy benefits, which leaves the reimbursement for a great deal of clinical work, from immunizations and point-of-care testing to medication management and chronic-care support, sitting on the table. Enrolling the pharmacy and its pharmacists with medical insurance carriers as providers opens a second stream of revenue for services the team is already delivering, and because it runs on the medical side rather than through a PBM, it is not subject to the same reimbursement pressure and clawback risk.
The reason more pharmacies have not done it is that credentialing takes months and months, involves a different set of applications, attestations, and contracts for every carrier, and tends to stall the moment a question goes unanswered. Matt Gibbs spent more than eleven years inside Tennessee healthcare regulation, including as deputy general counsel at the Department of Health, and he manages the process end to end, from the initial applications and CAQH profile through payor contracts, effective dates, and the re-credentialing cycles that follow, so the pharmacy can keep delivering pharmaceutical care while the paperwork moves.
Credentialing is included in the Growth membership tier, which means the same flat monthly fee also covers unlimited attorney access, document review, and the compliance work that surrounds a growing practice. Once the first reimbursements arrive, the membership typically pays for itself many times over, and the pharmacy has a provider relationship with the carriers that lasts well beyond the enrollment.
What we handle
Every step of enrolling with medical insurance carriers, and the contracts that come with it.
Initial applications for the pharmacy and its pharmacists with commercial carriers, Medicare, and TennCare managed-care plans.
CAQH profiles, attestations, follow-ups, and the steady pressure that keeps a months-long process moving.
Reviewing participation agreements, fee schedules, and terms before you sign them.
Tracking renewal cycles and keeping every enrollment current so reimbursement never lapses.
Guidance on documentation, coding expectations, and the records that support a clean claim.
Working through enrollment denials, terminations, and reimbursement disputes with carriers.
The Growth tier, at $2,200 per month, covers credentialing with medical insurance carriers along with everything in the On Call and Compliance tiers: unlimited attorney access, document review and drafting, and inspection readiness. One flat monthly fee, month to month, with no hourly meter running while the applications move.
Common questions
Credentialing is the process of enrolling the pharmacy and its pharmacists with medical insurance carriers so they can bill as providers for clinical services rather than only billing pharmacy benefits through a PBM. It matters because it opens a stream of reimbursement for work the pharmacy is often already doing, and because that revenue runs on the medical side, where the reimbursement rules and audit pressures are different.
Plan on months and months. Each carrier has its own application, its own review cycle, and its own list of follow-up questions, and the timeline stretches every time an application sits waiting on a document or an answer. The single biggest factor in how fast it moves is having someone whose job is to keep every application moving at once.
Yes, in the Growth tier. At $2,200 per month it includes credentialing with medical insurance carriers along with unlimited attorney access, document review and drafting, and the compliance and inspection-readiness work in the lower tiers. Pharmacies that only need guidance and review can start with On Call or Compliance and move up when they are ready to enroll.
It depends on the carrier, the plan, and the pharmacist’s scope of practice under Tennessee law, but immunizations, point-of-care testing, medication therapy management, and certain chronic-care and collaborative-practice services are common starting points. Part of the credentialing work is mapping the services the pharmacy already provides against what each carrier will reimburse, so the enrollment is built around revenue that is actually there.
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