Carelon Behavioral Health is the USA’s biggest and prominent behavioral health management company. It is serving more than 60 million people in the United States with more than 150,000 providers in their network. In 2025, they issued new guidelines that state providers must ensure accuracy in their data in the CAQH profile.
In this blog, we will discuss how, as a healthcare provider, you can take steps to stay current with guidelines. We will share useful information that will help in compliance with Carelon behavioral health provider data verification.
Carelon Behavioral Health New Requirements
In a clear statement issued by Carelon Behavioral Health issued the following statement:
“Carelon Behavioral Health continuously works to ensure the accuracy of our Provider Directory. The Consolidated Appropriations Act of 2021 (CAA) and additional state regulations require Carelon to verify the accuracy of data included in our provider directories within specified timeframes. Additionally, the federal Notice of Benefit and Payment Parameters regulation requires an annual submission of providers offering telehealth services.
Carelon has also notified behavioral health practices of the consequences they may face in case of non-compliance, such as:
“Failure to confirm the accuracy of your provider data in accordance with these requirements may result in suppression from Carelon Behavioral Health’s provider directory.”
These statements illustrate that mental and behavioral health experts must now adhere to periodic updates. This applies to all providers offering therapies, consultation at the clinic, and telehealth as well. So now mental health practices are required to first check their active status and then update it accordingly.
Importance of CAQH Profile
CAQH (Council for Affordable Quality Healthcare) is a centralized digital record of a healthcare provider’s professional and practice information. It plays a vital role in your clinical practice because the insurance companies and healthcare organizations use it for credentialing, enrollment, and claims processing. It is recommended that behavioral health and medical providers update the data periodically. An up-to-date CAQH profile ensures smooth billing operations, timely payments, and compliance with regulations.
CAQH Verification Requirement Timeframes
The compulsory verification requirements for providers vary by payers. Commercial and Medicare both see the process slightly differently. Let’s discuss the verification requirement timeframe:
Commercial lines of business
Providers who wish to remain active with commercial insurance programs are advised to attest and update their CAQH profile every 3 months or 90 days. Commercial insurers rely on CAQH Proview as a standalone source for verification of a provider’s expertise and experience.
Any delays or lapses in this process may prompt automatic suspension of patient referral privileges. Suspended or delayed credentialing can block providers from seeing their regular patients in many in-network programs. Beyond this typical quarterly attention, payers also require providers to go through a complete re-credentialing process after a 2-3 year gap.
Medicaid/Medicare/All other lines of business
For Medicare and Medicaid programs, the revalidation process is different than commercial payers. CMS programs rely on their system, known as PECOS (Provider Enrollment, Chain, and Ownership System), for enrollment, credentialing, and revalidation purposes.
The federally run program Medicare requires providers to go through a revalidation process every 5 years. Podiatrists must adhere to the 3-year rule if they are practicing as a DMEPOS supplier.
In compliance with above mentioned rules, Carelon wants providers in their network to attest their data every 90 days so they can stay in their provider directory.
Why Now? The End of “Ghost Networks”
The question arises, why did Carelon Behavioral Health issue this statement, and what’s the whole idea behind it? As per the Consolidated Appropriations Act 2021 healthcare compliance guidelines require Carelon to verify the accuracy of provider data in their directory. This step not only helps Carelon but also becomes an informative tool to end the ghost networks in the directory.
The ghost networks in almost all insurances, where a provider has either moved to a new location, changed their phone number, or state, and is not taking new patients. This becomes more pronounced when patients need to find a behavioral health specialist in their area urgently. So, it becomes troublesome for patients to find a new therapist or have to travel far out to search for the same provider.
By suppressing the providers in their directory, only attested and verified providers will show in their central directory, making it easy for patients to locate them and reach out for treatment.
The “Federally Governed” Data Elements You Must Check
If you are a provider and haven’t gone through the attestation process or your in-house team has done the process previously, here are the essential elements you must add for this purpose, including:
| • Name** | • Languages Spoken |
| • Address** | • Whether accepting new patients |
| • Telephone/Fax Number** | • Telehealth Services |
| • After-hours Telephone Number | • Handicap Accessibility |
| • Office Hours | • Public Transportation |
| • Email Address** | • Cultural Competency Training |
| • URL/Website Address** | • Covered Networks |
| • NPI & License Number | • Board Certification(s) |
| • Clinical Specialty/Specialties** | • Group Affiliation(s) |
| • Gender | • Hospital Affiliation(s)/Admitting Privileges |
| • Ages Seen | • Any information that may affect access
and availability to patients or other state-specific requirements |
It is mandatory for psychologists and psychiatrists to fill in all the relevant details on the Carelon portal so their data remains current. If these guidelines are not followed, it has far-reaching effects on the revenue cycle for solo practices and physician groups running coordinated care clinics.
The Provider’s Workflow: CAQH vs.The Carelon Portal
The CAQH Advantage: The “One-and-Done” Method
CAQH ProView is the primary tool for updating your profile once every 3 months, since most providers already use CAQH for credentialing and stay updated with any issues. It is one of the easiest methods because once you update your practice and other relevant data status, this information will automatically be shared with Carelon’s directory. CAQH ProView synchronizes the data for all major payers daily, including UHC and Aetna
After updating, providers must authorize a release of their profile information specifically to Carelon Behavioral Health within CAQH. If you fail to do so, the updates will remain invisible to Carelon despite being in the CAQH system. You can access this via the CAQH Provider Directory Snapshot at https://proview.caqh.org/login/.
The Carelon Portal: When to Go Direct
Providers who don’t use CAQH or are not willing to participate in CAQH can also verify or attest their data within the Carelon network. The process for this is fairly straightforward. You can log in to the Carelon Behavioral Health Provider Portal using your existing ProviderConnect credentials. Select “Update Demographic Information”. Scroll to the bottom and select “Attestation”. Update the necessary data elements and click “Save Attestation” to finalize.
Providers can also see mistakes or discrepancies in their Carelon directory listing that aren’t reflecting CAQH updates; the portal is the place for targeted, plan-specific corrections. Make the relevant amendments and reduce the headaches.
Pro-Tip: Assign a “Data Lead”
Clinicians should know that the 90-day attestation clock is relentless and recurring. Typically, they should not be spending their clinical time on administrative data entry. For better and seamless recredentialing, it is best for practices to designate a front-office staff member or a dedicated “Data Lead” to own the CAQH and Carelon logins.
The outsourced credentialing team should be responsible for checking the 90-day verification requirements for all “federally governed data elements,” such as name, address, specialty, and telehealth availability. This way, providers can offload this burden and focus on clinical matters.
Visual Checklist for Providers
For better
| Feature | CAQH ProView | Carelon Provider Portal |
| Primary Use | Universal updates for multiple payers | Carelon-specific data and attestations |
| Frequency | Daily feed to Carelon. | Immediate manual update. |
| Effort Level | Low (One update for all). | Moderate (Manual entry). |
| Key Requirement | Must authorize release to Carelon | Use ProviderConnect credentials |
Steps to Verify and/or Update Data Accuracy
CAQH Participating Providers:
- Go to your CAQH Provider Directory Snapshot at https://proview.caqh.org/login/.
- Update Practice Location provider data elements as necessary and confirm the accuracy.
- You must authorize a release of individual profile information to Carelon Behavioral Health within CAQH for information to be visible within Carelon Behavioral Health’s Provider directory.
- For questions about CAQH, please contact CAQH directly at 888-599-1771. Chat support is also available at https://proview.caqh.org/PR.
Non-CAQH Participating Providers:
- Provider data information can be updated and/or attested to by logging in to the Carelon Behavioral Health Provider Portal at the following link: https://providerportal.CarelonBehavioralHealth.com/index.html#/login.
- Log in using your ProviderConnect credentials.
- Choose “Update Demographic Information”.
- Scroll to the bottom of the page and choose “Attestation”.
- Update data elements as needed and click “Save Attestation.
Impact on Your Revenue Cycle
Provider data accuracy is the backbone of revenue cycle management. For providers in the Carelon network, it is important for them to update their credentialing status without any delay.
The Direct Link Between Data and Claim Denials
The major outcome of inaccurate provider data is one of the most common reasons for claim rejections and denials. Insurance reimbursement and adjudication systems rely on a “match” between the information on your submitted claim and the data stored in their provider directory.
Carelon in-network providers must understand that if the claim is submitted in the final days when your credentialing data is about to expire, it is likely that during the claim processing, your CAQH may have already expired. Until the data is attested, your claim will remain denied.
Similarly, if your practice moves or opens a new location and you fail to update and attest to this new address, a claim submitted from that site may be flagged. The system may not recognize the new location as being contracted, leading to denials that incorrectly label you as “out-of-network” for that specific encounter.
Moreover, if your directory information is outdated, claims may be rejected before they are even processed because the service location does not match the “federally governed” address on file.
Payment Delays and Legal Consequences
Failure to update can open a plethora of problems for healthcare providers, leading to claim denials. Besides denials, it can trigger specific regulatory penalties that pause your cash flow and become a bottleneck.
As noted in the Carelon update, regulations like California Health and Safety Code Section 1367.27 explicitly allow payers to delay payment or reimbursement of claims if a provider fails to respond to data accuracy notifications.
Similarly, if your data is not confirmed, Carelon may suppress your practice from the provider directory. While this stops new patients from finding you, it can also create administrative “red flags” that complicate the processing of existing claims. The patient pool can shrink, and new patient intake will become difficult if this continues for a longer period.
Summary for Providers
| Impact Area | Consequences of Inaccurate Data | Benefit of 90-Day Attestation |
| Claim Status | Denials for “Invalid Location” or “Out-of-Network” | Clean claim submission and “Auto-Adjudication. |
| Payment Speed | Legal delays in reimbursement (e.g., CA Health Code) | Timely reimbursement and consistent cash flow |
| Visibility | Suppression from the public provider directory | Continued access to care for members and new referrals |
Conclusion
Providers in Carelon networks have to comply with the new CAQH updates so they can keep treating patients without disruptions. Commercial insurance companies require personal attestation after every 90 days, whereas Medicare requires providers to go through a complete re-credentialing process after 5 years and 3 years for podiatry practices offering DME and orthotic devices.
Providers now must comply with this regulation and update their data through the CAQH ProView portal. This not only benefits their patients but also plays a crucial role in attracting new patients who require medical care. Medheave Medical Billing Company is a renowned organization that helps behavioral health and therapy providers with billing and comprehensive revenue cycle management, including updating CAQH data. We assist all healthcare institutions and group practices in re-credentialing, revalidation, in-network and out-of-network privileges, etc. Contact us for streamlining your revenue cycle management and tackling compliance issues.
