Skip to content Credex Healthcare delivers pediatric billing and coding services built specifically for the volume and variability that children’s care practices face every day. From high-volume preventive care and immunization clinics to developmental pediatrics and pediatric subspecialties, we manage the full billing cycle, so your front desk, nurses, and physicians stay focused on the patients in the exam room, not the claims sitting in a denial queue.
With a 99.9% claim acceptance rate, Credex Healthcare optimizes revenue cycle management from patient check-in to final payment. Our billing specialists handle insurance claims, Medicaid, and pediatric-specific coding, ensuring accurate claims and higher reimbursements.
First-Pass Claim Acceptance Rate Across Pediatric Payers
Hrs. of Claim Submission Turnaround After Charge Entry
Nationwide Insurance Payers, Including Medicaid Plans
Immunization Billing Audit Compliance on All Vaccine Claims
Before it leaves our system, every pediatric claim undergoes an organized review based on the unique issues that often arise when paying for children’s practices. We check that the preventive care CPT code matches the patient’s exact age on the day of service, not the age at the time of booking. We ensure that the correct vaccine product codes are grouped with the right vaccine delivery codes (90460 and 90461). We also ensure that guidance paperwork is available when Medicaid needs it for payment. We make sure that any sick visit reported alongside a well-child visit has a -25 marker, supported by a separate problem report, and that the ICD-10 code chosen for each diagnosis is as exact as possible. Before a claim gets to the payer, it goes through these four checks.
Our pediatric billing services in the USA cover the following:
We prepare and electronically submit pediatric claims within 24 hours of charge entry, applying age-specific preventive care codes, immunization bundles, and correct modifier assignments before every transmission.
We credential and enroll pediatric providers with Medicaid managed care organizations, CHIP plans, and commercial payers across all active states, managing re-attestation cycles to keep billing uninterrupted.
Every denied pediatric claim receives a root-cause review within 24 hours. Whether the denial is due to an age-band mismatch, missing counseling documentation, or a Medicaid unit limit issue, we appeal or correct and resubmit with supporting documentation.
Our certified coders audit well-child visit notes, sick visit documentation, and immunization records to confirm that billed codes reflect what was documented, and that no billable service is left uncaptured.
We manage prior authorization requests for developmental evaluations, behavioral health referrals, specialist procedures, and any pediatric service that commercial or Medicaid payers require pre-approval before the visit.
From eligibility verification at scheduling through payment posting and AR recovery, we manage your complete pediatric revenue cycle so that no billed service ages for more than 60 days without active follow-up.
Credex Healthcare tracks pediatric payer rules by state, plan type, and program. This way, no matter where your practice is based, your claims will be sent with the right codes, units, and supporting documents that each provider needs. Our staff is made up of experts who are always up to date on the latest changes to the laws that govern pediatric practice in each state.
We manage billing across state Medicaid fee-for-service programs and CHIP plans, applying state-specific vaccine reimbursement rules, well-child visit periodicity schedules, and managed care organization submission requirements.
We handle prior authorization, in-network rate verification, and preventive care billing under commercial plans from BCBS, Cigna, Aetna, UnitedHealthcare, and regional carriers serving pediatric populations.
Pediatric practices operating within FQHCs receive specialized billing support under the prospective payment system, including the correct application of encounter rate and wraparound billing for qualifying services.
We bill pediatric telehealth visits and school-based health program claims under state-specific Medicaid telehealth rules and school-based services reimbursement frameworks, capturing revenue that many practices miss.
Credex Healthcare offers specialized billing for children, with a dedicated billing team that handles rejections before they happen. Our team handles all prior eligibility checks for Medicaid patients quickly and accurately, as well as provider registration gaps with new employees. Credex Healthcare addresses these issues by implementing a process that carefully reviews every claim before submission.
Before we send a claim, we make sure that the provider NPIs for billing and providing services are current, correctly linked to the group TIN, and registered with the Medicaid managed care organization or private plan in question.
Our coders make sure that the preventive care codes are correct for the patient's age on the date of service and that the immunization delivery codes are matched with the correct HCPCS codes for the vaccine product.
We review notes from well-child visits, sick visits, and vaccine records to ensure the paid services are backed by the clinical record and that marker -25 is used when there was a separate problem-oriented visit.
We manage authorization requests for behavioral health evaluations, developmental screenings requiring specialist referrals, and any service category in which commercial or Medicaid plans mandate pre-approval for reimbursement.
Before sending in a claim, our team checks it against the rules for each payer's Medicaid cycle schedule, EPSDT billing, vaccine unit limits, and commercial plan preventive care benefit.
AR Follow-Up
Every open pediatric claim is tracked through an organized AR follow-up process that is broken down by payer age bin. Claims that go unpaid or unanswered for more than 45 days are escalated in accordance with established procedures.
Pediatric practices are experiencing significant revenue losses due to three common billing oversights. First, immunization visits are often underbilled when incomplete documentation leads to the use of the lower-paying 90471 code instead of 90460, costing practices $12 to $28 per vaccine. Second, for well-child visits, failure to apply the -25 modifier for acute issues during preventive exams results in denials averaging $65 to $110. Lastly, Medicaid’s changes to retroactive eligibility can cause clean claims to be rejected if submitted incorrectly, necessitating time-consuming corrections and resubmissions. Credex Healthcare’s specialists can identify and rectify these issues, ensuring practices don’t lose out on hard-earned revenue.
We submit complete, age-verified pediatric claims with correct preventive care codes, immunization bundles, and modifier assignments, targeting first-pass acceptance and eliminating revenue loss to preventable coding errors.
Our pediatric coding specialists review every well-child note, immunization record, and sick visit documentation to ensure billed codes maximize legitimate reimbursement and satisfy payer documentation requirements.
Prior Authorization Management
We initiate and track prior authorizations for behavioral evaluations, specialist referrals, and procedure-specific services, preventing post-service denials on authorized visits that billing staff failed to document correctly.
Every rejected pediatric claim is reviewed within 24 hours, categorized by denial reason, and either corrected and resubmitted or formally appealed with clinical documentation within payer filing deadlines.
We get pediatricians and advanced practice providers approved by Medicaid managed care organizations, CHIP plans, and commercial payers. We also handle re-attestation cycles so that billing doesn't stop when a provider changes.
The monthly reports cover sections such as clean claim rates, rejection patterns by code group, vaccine billing performance, AR age by payer, and collecting trends. This way, practice administrators can make practical choices based on the data.
Years of Pediatric Revenue Cycle Expertise
Provider Enrollment Coverage for Active Pediatric Rosters
HIPAA Compliance Rate Across All Billing Operations
Support for Pediatric Practices and Billing Inquiries
Customized Billing Workflows for Every Practice Model
MD
Angela
“My Medicaid requests for immunizations were always turned down, and I could never figure out why. Credex figured it out in the first week: our biller was submitting 90460 without the coaching paperwork Medicaid needed. Once they fixed the process, our vaccine payments began to go through on the first application. That alone got us back thousands of dollars that we had written off.”
Practice Administrator
Hendricks
“We have four physicians and two nurse practitioners, and managing Medicaid credentialing for each of them across three managed care organizations was consuming hours of staff time every week. Then Credex took care of that for us. Since we switched companies, our bills have not been held up because of problems with registration. That alone makes them worth every penny we pay them.”
MD
Kevin
“In the field of developmental pediatrics, billing is its own expertise. It is really hard to keep track of how the prior-permission rules for developmental exams change from payer to payer. Credex built a permission-tracking process that works with our mix of services. In the first two months, our rejection rate for developmental evaluation codes dropped from 22% to less than 6%. Our income has been affected in a big way.”
DO
Anora
“When you work in a small clinic where 90% of the patients are on Medicaid, every billing mistake affects what the office can do for the community. After a string of rejections for well-child visits, I brought in Credex. They found that our code was always using the wrong age bands. For the first time, our first-pass rate went over 97% in just 60 days. Our days in AR went from 61 to 33.”
CFO
James
“We have three sites, and the number of video patients has grown a lot. Our former billing company did a poor job at best of billing pediatric telemedicine under Washington Medicaid rules. Credex quickly knew the telehealth billing rules for each state, and within the first billing cycle, our telehealth claim rejection rate dropped from over 30% to less than 4%.”
Practice and Payer Mix Assessment
To figure out where and why your practice is losing money, we start by examining your current patient population, payer mix, and rejection history. For pediatric practices, this evaluation focuses on your Medicaid and CHIP volume, your vaccine billing process, and the accuracy of your current preventive care coding.
Credentialing and Payer Enrollment
We check the qualifications and registration status of providers with all commercial payers, CHIP plans, and Medicaid managed care organizations in your area. If we find any gaps, we start the registration process right away and make sure it goes all the way through.
Documentation and Authorization Workflow Setup
For same-day visit modifier -25 needs, we work with your clinical team to set up paperwork steps. A practice with a 97% first-pass rate is different from one with a 20% rejection rate because they get these processes right before claims are sent in.
Clean Claim Submission
Before an electronic claim is sent, each juvenile claim is checked to ensure that age-band accuracy on preventive care codes, the right match of vaccine delivery codes, modifier completeness, and ICD-10 specifics are met. With clearinghouse proof, claims are sent within 24 to 48 hours of charge entry.
Denial Management & Follow-Up
Denied pediatric claims are reviewed and categorized within 24 hours of receipt. Our denial team distinguishes between correctable coding errors, documentation deficiencies, authorization issues, and payer adjudication errors, then takes the appropriate corrective action for each category.
Reporting & Ongoing Optimization
Monthly performance reports include your clean claim rate by payer, denial rate by code category, immunization billing performance metrics, AR aging breakdown, and net collections trend. We review this data with your practice leadership each month and adjust the billing workflow to new payer policy changes and any emerging patterns in your denial data.
Credex Healthcare focuses on infant bills and emphasizes the importance of accuracy to avoid revenue loss. Pediatric billing has noted that regular billing companies don’t always pay attention to, like how different age groups of children have different CPT numbers, and how complicated it is to bill for immunizations. To avoid losing money, it is very important to know the state-specific Medicaid rules for EPSDT bills. Credex encourages pediatric practices to work with experts to make sure that claims are maximized while patient care remains the focus. This helps the practices’ overall financial health.
Our billing staff only works with juvenile and pediatric specialist offices. We keep up with the latest Medicaid plans, billing rules for immunizations, EPSDT standards, and code rules for preventive care for all age groups.
You work with a named pediatric billing account manager who knows your providers, your payer contracts, and your patient population. When you inquire, you will be talking to someone who already knows how your practice bills are.
Every month, we send each client a full performance report that includes the number of claims, the first-pass acceptance rate, the number of denials broken down by payer and code group, vaccine billing measures, and net collections.
Credex Healthcare does all of its billing in a way that is fully HIPAA-compliant. This includes encrypting EHR data integration, sending claims securely, and making sure that only authorized people can see all patient information and billing data.
Three revenue leaks in pediatric practices without a specialist billing partner include incorrect immunization billing, omission of the -25 modifier on same-day visits, and Medicaid eligibility discrepancies. It can cost $12 to $28 per shot to be misbilled, and $65 to $110 could be lost if visits are refused. Also, changing managed care plans can lead to past rejections that require extensive manual work to fix, which can be too much for in-house staff to handle. With the right payment procedures in place, these problems can be fixed.
Credex Healthcare gives pediatric offices that qualify a free check of their bills. The audit looks at your current rejection rate by payer and code area, the accuracy of your vaccine billing, the accuracy of your preventive care code across age groups, any breaks in active registration or credentialing, and your AR aging profile. You don’t have to make a promise after the audit, and most practices get at least one clear, actionable income recovery finding from the first review meeting.
Pediatric medical billing covers a wide range of services pediatricians provide, such as checkups to prevent illness, screenings, immunizations, and care for long-term conditions. For each service, it’s important to use the right CPT codes, modifiers, and ICD-10 codes to show that the service is medically necessary. A full billing service checks if the patient is eligible, makes sure the provider is qualified, keeps track of prior authorizations, handles denials, posts payments, and follows up on outstanding accounts.
The most billed and miscoded CPT codes in pediatric practice are primarily for preventive care and immunization administration. Preventive care codes range from 99381 for infants under one year to 99385 for patients aged 18 to 39, with established patient codes from 99391 to 99395. The chosen code must correspond to the patient’s exact age to avoid claim denials, often caused by misassignment within a year. Immunization administration uses code 90460 when face-to-face counseling occurs, while 90461 applies to additional vaccine antigens. Without counseling, codes 90471 and 90472 are used at lower rates. Each vaccine requires a specific HCPCS or CPT product code along with the correct administration unit count. Other frequently billed codes include 96110 for developmental screening, and 99213 and 99214 for acute visits, alongside applicable ICD-10 codes to establish medical necessity for services on the same date.
Reducing claim denials in pediatric practices involves addressing key root causes. The preventive care codes range from 99381 for babies younger than 1 year to 99385 for people ages 18 to 39, and the known patient numbers range from 99391 to 99395. To avoid claim rejections, which are often caused by the wrong code being assigned within a year, the code must match the patient’s exact age. Each vaccine needs its own HCPCS or CPT product code and the right number of delivery units. Other commonly billed codes include 96110 for developmental screening and 99211 and 99213 for urgent visits, along with the right ICD-10 codes to show that the services were medically necessary on the same date.
Immunization claim rejections in pediatric billing are usually caused by four billing process mistakes that can be avoided. A very important step is to review the claims before they are sent in to make sure they are correctly coded. This includes making sure that the preventive care CPT codes are matched to the patient’s age, that the -25 modifier is used for same-day visits, that immunization codes are matched with face-to-face counseling, and that the most specific ICD-10 codes are used. Practices should also make sure that the person is still eligible for Medicaid on the day of the service because eligibility can change, and they should also make sure that the person has permission to receive services before the meeting.
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At Credex Healthcare, we know how frustrating it is when claims are denied. That is
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