What is a Qualified Health Provider (QHP)?

Q: Is a QHP the same as a Qualified Health Plan?

No. A Qualified Health Professional refers to a licensed provider, while a Qualified Health Plan is a type of insurance under the Affordable Care Act.

Q: Why does QHP status matter for billing?

QHP status is required to bill, supervise staff, and attest to compliance in CMS programs like Chronic Care Management and Collaborative Care.

Q: What’s the difference between a QHP and a non-qualified clinical staff member?

QHPs are licensed to make clinical decisions and bill for services, while non-qualified staff can only assist under QHP supervision.

Q: Can a Registered Nurse (RN) be a QHP?

In most Medicare programs, RNs are not considered QHPs but may qualify under specific Medicaid or state-based program rules.

A Qualified Health Professional (QHP) is a licensed or credentialed clinician authorized to provide or oversee certain healthcare services, often as defined by federal, state, or payer-specific guidelines. The term is commonly used in medical billing, care coordination, and regulatory compliance — especially in the context of value-based care programs like Chronic Care Management (CCM) and Principal Care Management (PCM).

QHPs typically include physicians, nurse practitioners, physician assistants, and other licensed practitioners such as clinical psychologists or social workers, depending on the service and setting. While “QHP” can also refer to Qualified Health Plans under the Affordable Care Act, in care delivery and billing, it refers to the qualified provider role, not an insurance product.

Key Components of a Qualified Health Professional

Holds a valid license or credential recognized by state or federal authorities
Authorized to diagnose, treat, and/or supervise care within their scope of practice
Meets CMS or payer-defined criteria for services like CCM, PCM, TCM, or CoCM
May include physicians, NPs, PAs, psychologists, LCSWs, and others depending on service
Plays a central role in billing, documentation, and clinical oversight
Often cited in EMR workflows, billing requirements, and compliance policies

A three-column table titled “Collaborative Care Model (CoCM)” compares the roles of the Primary Care Provider, Behavioral Healthcare Manager, and Psychiatric Consultant. The Primary Care Provider leads the overall care plan, initiates CoCM workflows, and typically bills for CoCM CPT codes (99492–99494). The Behavioral Healthcare Manager coordinates care using a patient registry, tracks symptoms with rating scales, and interfaces with patients directly. The Psychiatric Consultant supports the team indirectly by reviewing caseloads weekly, recommending treatment adjustments, and advising on the care plan, but does not see the patient directly.

The Role of a QHP in Care Delivery

Qualified Health Professionals (QHPs) play a central role in initiating, delivering, and overseeing care across a wide range of outpatient and value-based programs. Depending on the service, a QHP may work independently or as part of a team — and is often the one who meets the credentialing requirements to bill or supervise billable services under Medicare or commercial payer rules.

In practice, a QHP might:

Conduct patient assessments and develop care plans
Oversee care coordination for Chronic Care Management (CCM), Principal Care Management (PCM), or Transitional Care Management (TCM)
Supervise other clinical team members such as RNs or care coordinators
Sign off on documentation and fulfill billing attestation requirements
Provide direct patient care within their licensed scope
Participate in compliance reviews and quality reporting

Because QHP status is defined differently depending on the payer and program, organizations often reference CMS guidance or state-specific rules to determine whether a provider qualifies.

Who Qualifies as a QHP?

There’s no single, universal definition of a Qualified Health Professional (QHP) — instead, eligibility depends on the care setting, the payer (e.g., Medicare or Medicaid), and the specific program or service being billed.

Common QHP Types

Most payers and regulatory bodies consider the following licensed roles to be QHPs:

Physicians (MD/DO)
Nurse Practitioners (NP)
Physician Assistants (PA)
Clinical Psychologists
Licensed Clinical Social Workers (LCSW)
Other advanced or licensed clinicians, depending on state scope of practice and program rules

Credentialing Requirements

To be recognized as a QHP, the provider must typically:

Hold a valid license to practice in their state
Be enrolled as a Medicare or Medicaid provider (if billing federally funded programs)
Be listed on the practice’s credentialing roster for payer contracts
Maintain any program-specific training or documentation required (e.g., CoCM workflows, risk assessments)

In some cases, state Medicaid agencies or commercial payers may extend QHP status to other licensed professionals such as RNs, clinical pharmacists, or care managers — especially if working under supervision.

Billing and Reimbursement Involving QHPs

The term Qualified Health Professional (QHP) is commonly used in CMS guidance and payer policies to indicate who is authorized to bill for — or supervise billing of — certain healthcare services. In many cases, QHP status is the key determinant for care management billing eligibility.

When QHP Status Matters

To bill for or supervise services like CCM or PCM, a QHP must:

Personally provide the service
Or supervise non-QHP clinical staff, such as RNs or care coordinators
Meet all documentation and attestation requirements
Be recognized as a billing provider by Medicare or the relevant payer

In CoCM (Collaborative Care Model) billing, for example, only a QHP (usually a PCP or NP) may report CPT codes 99492–99494, even though other team members deliver portions of care.

A table outlining care programs that require a Qualified Health Professional (QHP) for billing. It lists four programs: Chronic Care Management (CCM), Principal Care Management (PCM), Transitional Care Management (TCM), and the Collaborative Care Model (CoCM). Each row includes the QHP's role in that program — such as supervising staff, leading care plans, or initiating the model — and the related CPT codes. For example, CCM involves codes 99490 and 99439, while CoCM uses 99492 to 99494.

Frequently Asked Questions about QHPs

1. What is a QHP?

A Qualified Health Professional (QHP) is a licensed or credentialed clinician who is authorized to provide or supervise certain healthcare services. The term is commonly used in medical billing, care coordination, and compliance documentation to indicate which providers meet payer or regulatory requirements.

2. Is a QHP the same as a Qualified Health Plan?

No. While “QHP” can also refer to Qualified Health Plans under the Affordable Care Act, in clinical and billing contexts, it refers to a Qualified Health Professional — a person, not a product. The glossary definition on this page focuses on the provider role.

3. Who qualifies as a QHP in Medicare care management programs?

In most cases, QHPs include:

Physicians (MD, DO)
Nurse Practitioners (NP)
Physician Assistants (PA)
Clinical Psychologists
Licensed Clinical Social Workers (LCSW)

Some payers may recognize other licensed professionals depending on scope of practice and state laws.

4. Why does QHP status matter for billing?

QHP status is required to:

Bill directly for certain services
Supervise clinical staff providing time-based or care management services
Attest to compliance in CMS programs like CCM, PCM, and CoCM
Without a QHP, many of these services cannot be billed or reimbursed.

5. What’s the difference between a QHP and a non-qualified clinical staff member?

A QHP is licensed to make clinical decisions, diagnose, and bill for services. Non-qualified staff (like RNs or MAs) can provide support but must be supervised by a QHP for services to be billable.

6. Can a Registered Nurse (RN) be a QHP?

It depends on the program and the state. RNs are generally not considered QHPs for billing purposes under Medicare but may qualify in certain Medicaid programs or under supervision when documentation requirements are met.