Qualified Provider

Medicaid Toolkit

States laws and rules define the scopes of practice for clinical providers who are authorized to practice within the state. States may require licensure, certification, and/or registration for authorization of services.

Qualified provider is defined by the Centers for Medicare & Medicaid Services (CMS) in the Federal Register (42 CFR §440.110) [PDF]:

(c)(2) A "speech pathologist" is an individual who meets one of the following conditions:

1. Has a certificate of clinical competence from the American speech and Hearing Association [sic]
2. Has completed the equivalent educational requirements and work experience necessary for the certificate
3. Has completed the academic program and is acquiring supervised work experience to qualify for the certificate

(c)(3) A "qualified audiologist" means an individual with a master's or doctoral degree in audiology that maintains documentation to demonstrate that he or she meets one of the following conditions:

1. The State in which the individual furnishes audiology services meets or exceeds State licensure requirements in paragraph (c)(3)(ii)(A) or (c)(3)(ii)(B) of this section, and the individual is licensed by the State as an audiologist to furnish audiology services.
2. Have a Certificate of Clinical Competence in Audiology granted by the American Speech-Language-Hearing Association.

1. Have successfully completed a minimum of 350 clock-hours of supervised clinical practicum (or is in the process of accumulating that supervised clinical experience under the supervision of a qualified master or doctoral-level audiologist); performed at least 9 months of full-time audiology services under the supervision of a qualified master or doctoral-level audiologist after obtaining a master's or doctoral degree in audiology, or a related field; and successfully completed a national examination in audiology approved by the Secretary.

Considerations

To be considered a qualified provider, professionals must meet certain eligibility requirements that differ from state to state. Some states issue a temporary license to clinical fellows (CFs) that may allow them to bill Medicaid, but this is not true for all states. Other states restrict CF billing to specific settings (e.g., schools, hospitals). This provision may exclude billing by (CF) providers in private practice. State Medicaid agencies often defer to the state licensure/regulatory board to establish requirements. Providers who relocate should check to see if licensure is reciprocal. If possible, communicate with the state Medicaid agency

Resources

• ASHA Requirements and Payer Policies for SLP Clinical Fellows
• ASHA's Medical Review Guidelines for Speech-Language Pathology Services
• Additional ASHA Resources on Qualified Providers
• IDEA: Qualified Providers