Network Access for Locum and Newly Hired Clinicians

A practice that hires a new clinician or brings in a locum needs that person billable on day one, but plans credential on their own schedule. Medicare has a specific locum tenens rule with a 60-day limit, Texas pays group joiners as in-network while credentialing runs, and some plans offer one-time provisional credentialing. Here is how to cover the gap.

For a practice, the expensive weeks are the ones between a new clinician's start date and the date each plan finishes credentialing. Patients are scheduled, the clinician is paid, and claims cannot be billed in network. Locum coverage raises the same problem in a different shape. Some of the gap can be closed with rules that already exist; some of it is a network problem in disguise, especially when a plan treats a new hire as a brand-new applicant to a closed panel.

How does Medicare handle locum tenens coverage?

Original Medicare has a specific rule in the Social Security Act, 42 U.S.C. 1395u(b)(6)(D). Payment may be made to a physician for services furnished by a second physician to the first physician's patients if the first physician is unavailable, the arrangement between them is "informal and reciprocal" or "involves per diem or other fee-for-time compensation," and the services are not provided by the second physician "over a continuous period of more than 60 days" (with an exception when the first physician has been called to active military duty as a reserve member). The claim must include the second physician's identifier and indicate that it meets these requirements.

Two limits matter. The statute speaks of physicians, so check how it applies before using it for other clinicians. And it covers a substitute for an absent physician; it is not a way to bill for a permanent new hire who is not yet enrolled.

What about permanent new hires in Medicare?

A new physician or non-physician practitioner gets billing privileges effective on the later of the date of filing an application that is later approved or the date of first service at the location (42 CFR 424.520(d)), with up to 30 days of retroactive billing "if circumstances precluded enrollment in advance" (424.521(a)(1)(i)). Changes of information and reassignments are processed within 90 days of receipt (42 CFR 405.818(c)). The practical rule is simple: file the enrollment and reassignment as soon as the hire is signed, not on the first day.

Do commercial plans ever pay a new hire before credentialing ends?

In Texas, they must for physicians who join a contracted group. Texas Insurance Code chapter 1452, subchapter C, "applies only to a physician who joins an established medical group that has a current contract in force with a managed care plan" (1452.102). Once the physician submits the information the plan needs to begin credentialing and agrees to the group's contract terms, the plan "shall treat the applicant physician as if the physician were a participating provider" for payment, including collecting copayments (1452.103 and 1452.104). The plan may leave the physician out of the directory while the application is pending (1452.105). If credentialing ultimately fails, the plan may recover the difference between in-network and out-of-network payments (1452.106). Subchapters D and E give similar treatment to certain podiatrists and therapeutic optometrists. See Texas network access laws.

Some other states have provisional credentialing rules, and some plans offer provisional credentialing by policy. One Louisiana Medicaid plan's policy, for example, allows provisional credentialing only for practitioners "applying for the first time" to its network, only once, and "for a time-period no longer than 60 calendar days." See provisional credentialing laws and credentialing deadline laws by state.

What if the plan says it is not adding anyone, even to a group?

Ask whether the plan has a group exception. Many published closures include one; see joining a participating group. If the plan insists the network is closed even to clinicians joining a participating group, request the written reason and check whether your new clinician brings something the plan lacks: a subspecialty, a language, evening hours, a location the existing group does not cover. A new hire who extends the group's reach into an under-served county is a stronger case than one who adds capacity where the plan already meets its standards.

Which delays are most avoidable?

Start before the start date. Collect licenses, DEA, board certification, malpractice face sheet, work history and references at offer acceptance.
Update CAQH ProView immediately and attest. Our sister service explains how CAQH ProView works.
Explain gaps in advance. A locum career creates many short engagements; plans may ask about any gap over six months. A clean timeline saves a round trip.
Answer requests the same week. Some plans close applications that go unanswered; Independence Blue Cross says behavioral health applications are closed if the provider does not respond within the designated timeframes and must then be resubmitted.
Track every plan separately. One slow plan can stall a schedule for months. White Glove Credentialing covers locum and telehealth credentialing in detail.

How do we help?

Routine credentialing for new hires belongs with White Glove Credentialing. We step in when a plan refuses to add the clinician, stalls past a state deadline, or treats a group joiner as a new applicant to a closed panel. We prepare the request, the evidence and the letters; you sign and send them, and we track the plan's response. We do not give legal advice. A Payer Network Dispute is $799 per payer, and the flat $1,500 win fee applies only if the plan approves the clinician. See pricing. Legal questions, such as what a contract term means or whether to pursue a hearing, belong with a healthcare attorney.

Common questions

How long can a locum physician bill under my Medicare number?

Under 42 U.S.C. 1395u(b)(6)(D), services by a substitute physician can be billed by the absent physician if they are not provided over a continuous period of more than 60 days, with an exception for physicians called to active military duty.

Can a new physician be paid in network before credentialing is finished?

In Texas, yes, for a physician joining an established group with a current contract, once the physician submits the required credentialing information (Tex. Ins. Code 1452.104). Elsewhere it depends on state law and plan policy.

When should a practice start Medicare enrollment for a new hire?

As soon as the hire is signed. Billing privileges begin on the later of the filing date or the first date of service at the location, and only 30 days of retroactive billing is available when circumstances prevented earlier enrollment.