Being in a health plan's medical network may not put you in its behavioral health network

Published 18 August 2026, revised 19 August 2026. Payer policies change. Every payer statement below links to the payer's own document, with the date it was published, so you can check whether it still says the same thing.

The words used here — payer, network, credentialing, enrollment — are explained in who is who in credentialing, along with who each of them refers to.

Two points from it are worth repeating, because everything below rests on them. A payer's agreement is usually with the practice rather than with each clinician working there, and clinicians are checked separately and then added to it. And being checked by a payer is not the same as being set up so that claims will be paid; those are two different pieces of work with two different finishing dates.

The same invented example runs through both articles, so it is repeated here for anybody who has not read the other one. Maya Okonjo is a counselor at Cedar Street Counseling, a practice with six clinicians. Northline Medical Billing handles Cedar Street's credentialing and enrollment, and does the same for eleven other practices. Many practices instead run this themselves, and everything here applies the same way when they do. Tom Reyes is one of Maya's patients. None of them are real.

What a carve-out is

Many health plans do not manage mental health and substance use benefits themselves. They hand some or all of it to a specialty behavioral health company, which may manage the behavioral health network, the credentialing, the authorizations — the permissions a payer requires before certain care is given — and the administration of claims. That arrangement is called a behavioral health carve-out, and the separate company is usually called a managed behavioral health organization, shortened to MBHO. Other plans keep the work in house, and behavioral health is simply part of the medical plan. Both arrangements are common, which is why this cannot be assumed either way.

Examples include Optum Behavioral Health, Carelon Behavioral Health, Lucet, and Magellan Health.

Being approved by one is not being approved by the other

This is the whole point of the article, and it is the part that costs practices money.

Two terms are worth pinning down before going further, because both are about to appear. The medical plan is the payer whose name the patient would recognize, the one on the insurance card. The carve-out company is the separate business standing behind it for mental health and substance use care. The patient generally has no idea the second one exists.

"Providers credentialed with the medical plan are not automatically credentialed with the MBHO — separate insurance credentialing applications and contracts are required."

You do not have to take a third party's word for it. Carelon Behavioral Health publishes its own network-entry process. New enrollment requests currently begin through Carelon's Payer Space in Availity, and Carelon can take a clinician's credentialing information from CAQH — the shared system where clinicians keep that information and authorize payers to read it, now run under the name DataSpring. Carelon states plainly that a provider "must be credentialed and approved before being added to the network".

What follows credentialing depends on who is joining. A practice that is not already contracted may need a participation agreement with Carelon of its own. A clinician joining a group that already holds one does not get a separate contract; once credentialing is approved, they are added to the group's existing agreement. That is the same group-versus-individual distinction the rest of this series describes, and it decides whether the work ahead is a contract negotiation or an addition to something already signed.

So what looks like one payer relationship can be two pieces of work. Each has an application, an approval date, and a date from which billing is allowed. Treating them as one row on a spreadsheet is how a practice ends up seeing patients it cannot bill for at the rate it assumed.

Put through the example: Tom hands over his insurance card at reception. The card says Anthem Blue Cross Blue Shield. It gives a member number, a group number and a telephone number, and Anthem is the only company named on it. When Tom sees his primary care doctor — a different practice altogether, on the other side of town — that visit is Anthem's to pay, and Anthem pays it.

Tom's therapy sessions are a different matter. Where his particular Anthem plan hands behavioral health to Carelon Behavioral Health, it is Carelon that manages the behavioral health network and decides whether Maya is in it — Carelon administers those services on Anthem's behalf. Tom has no reason to have heard of Carelon, and may find nothing on his card that mentions it, which is why the card alone cannot answer the question. Unless Cedar Street's arrangement covers Carelon's network and Maya has been credentialed for it, the sessions Maya has already provided are not in-network work. What can be recovered then depends on the benefit: some plans pay something out of network, and a single-case agreement is sometimes available for care already given. None of those are the rate Cedar Street expected, and none of them are certain.

The detail worth noticing is that this is not two rival companies failing to talk to each other. Elevance Health owns both Anthem and Carelon. Sharing a corporate parent does not merge the two credentialing processes, and the practice still has to complete both. Which plans carve the benefit out, and to which company, varies by state and by product, so the question has to be asked plan by plan rather than assumed from the name on the card.

Payment differs as well. Reimbursement for the same procedure code can vary substantially between the medical plan and the carve-out company, because the fee schedules are negotiated separately.

Medicaid usually doubles the work again

Many states pay for Medicaid behavioral health through managed care organizations, shortened to MCOs. Joining one of those networks does not remove the need to enroll with the state.

This one is not a matter of custom. Federal regulation requires the state to screen and enroll every provider in a managed care organization's network, and to revalidate them periodically, even where the provider's only working relationship is with the managed care organization. In practice the provider must be enrolled with the state Medicaid program, and must then satisfy the credentialing and network-participation requirements of each managed care organization it wants to join. Those are distinct processes run by different organizations, and only the first is enrollment in the strict sense.

So a practice in a state with four Medicaid managed care organizations does not have one Medicaid process to track. It has the state enrollment, plus a credentialing and network-participation process with each organization it wants to be paid by. The regulation does allow an organization to sign a network agreement while state enrollment is still pending, for up to 120 days, which helps the practice start sooner and adds one more date that somebody has to watch.

The companies change their names, and the old names stay in your records

Two of the four companies named above were called something else three years ago.

Beacon Health Options became Carelon Behavioral Health on 1 March 2023. That one was a straightforward rename by its owner, Elevance Health.

Lucet is a different case, and it is worth being precise about it. New Directions Behavioral Health did not simply rename itself. It merged with a company called Tridiuum, and the combined business launched as Lucet in January 2023. Anyone who worked those contracts at the time will remember that it was a merger.

This matters for record keeping rather than for clinical work. A practice's older files, older contracts and older correspondence will say Beacon and New Directions. Anything that stores payer names as plain text will end up holding several names for the same organization, with nothing to connect them.

Why this is difficult to keep on top of

The work described above is not one-off. Every clinician who joins has to be credentialed and added to each relevant behavioral health network separately, and every clinician who leaves has to be removed.

Behavioral health has high staff turnover. A survey of 471 behavioral health facility executives, covering 27,244 employees, published by OPEN MINDS in June 2022, found average turnover of 31.3%. Broken down by role in the same survey, clinical professionals were at 22.91%, mental health workers and psychiatric aides at 37.17%, and administrative support at 32.24%.

Those figures are four years old at the time of writing, and the full report sits behind a paid membership, so treat them as an indication rather than a current measurement. Even so, the direction is clear enough to plan around. Even at the lower clinical-professional rate in that survey, closer to a fifth than a third, a group of forty clinicians would expect around nine departures in a year. A practice replacing nine clinicians is adding and removing credentialing records continuously, across every payer it contracts with, and across the carve-out company behind each of those payers.

Northline, handling this for Cedar Street and eleven other practices, is doing that arithmetic for all of them at once. Somebody doing it for the clinicians of a single group is doing the same arithmetic over a shorter list. Each practice has its own clinicians joining and leaving, its own payers, and behind some of those payers a carve-out company with its own separate approvals to obtain and its own separate dates to watch.

What to take from this

If you track credentialing on a spreadsheet with one row per payer, it is worth checking whether that row is hiding a second piece of work behind it. The useful question is not the yes-or-no one, "is behavioral health carved out?", because the answer on its own does not tell anybody what to do next. For each payer and each product, the questions worth a column are these.

• For this exact product or line of business, who administers the behavioral health benefit, and which network applies?
• Who credentials the clinician for that network, and how is the request submitted?
• Which participation agreement and fee schedule apply — does the practice need a new agreement, or is the clinician being added to one the practice already holds?
• Who handles authorization, where authorization is required?
• Where does the claim actually go, and under which payer identifier or submission route?
• What is the effective date for this clinician, practice location and product — and is it prospective or retroactive?

Those questions can have different answers even within one company's arrangements. Carelon's own instructions route Anthem members and other Carelon-managed plan members differently for eligibility, authorization and claim-status work, and its claims guidance says the submission destination may vary by member. The company doing the credentialing is therefore not enough to determine where a claim goes. The name on the patient's card is where that enquiry starts. It is not where it finishes.