Supervision of Clinical Fellows and Audiology Externs: Billing and Payment Compliance

Supervision requirements of clinical fellows and audiology externs can vary widely by state, setting, and payer. It is important to consider all applicable requirements to ensure that you are billing appropriately. ASHA develops its own supervision standards to meet minimum standards for certification, but the final authority on billing and payment requirements is the patient’s insurance plan (payer), in compliance with state law. The following information provides general considerations across payers. However, requirements can vary even within a single payer—depending on the provider type, insurance plan, and setting—so it’s best to check with the patient’s plan directly. 

Additional information on supervision of assistants and graduate students is available at Supervision of Assistants, Gradute Students, and Clinical Fellows: Billing and Payment Compliance.

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State Law Considerations

Audiology externs are considered students in most states and do not typically hold licenses during their extern year, although this can vary—so, it is important to check with the state speech and hearing licensing boards directly. Most states have some type of preliminary license or registry for speech-language pathology clinical fellows (CFs); these laws vary, so it is important to check with your state licensing board. State laws provide guidance on supervision requirements for the clinical fellowship—that is, all steps that a CF is required to take in order to complete their fellowship and obtain a full license. A couple of states provide a full license upon graduation, but this is not common. Payers often have additional credentialing and/or supervision requirements, so it is important to ensure that you verify both state and insurance requirements. Licenses also convey state-specific scope-of-practice protections and limitations that CFs should understand.

ASHA Policies and Guidelines

ASHA’s supervision guidelines for audiology externs and  CFs and seeking certification are available on ASHA’s website for audiology and speech-language pathology applicants. Note that ASHA’s certification requirements for supervision may not match state or payer requirements. To bill appropriately, clinicians must ensure that they follow both state and individual payer supervision requirements.


If a CF holds a temporary or preliminary license to practice, they can enroll directly with Medicare, and they do not require additional supervision under Medicare policy. Supervisors of licensed and enrolled CFs should provide the level of supervision required by the state licensing board. Medicare does not have additional requirements for supervisors of licensed and enrolled CFs. If a CF cannot obtain a license and/or is not enrolled in Medicare, then they are considered students under Medicare regulations and require the same level of supervision as a graduate student in that setting. Please see the graduate students section for more details.

If the CF has a license, then they are considered a qualified provider under Medicare. In outpatient settings like private practices of clinics, the CF should enroll in and bill Medicare directly through their personal license and NPI number. If the CF is in an inpatient setting, licensure is still required, but the services are billed under the facility’s NPI. The CF develops and signs all documentation under the supervision requirements outlined under state law for their clinical fellowship.

In the rare case that an audiology extern holds a state license, they likely will not meet Medicare’s definition of a qualified provider―an individual who holds a master’s or doctoral degree, or equivalent education required to receive ASHA certification―and cannot enroll as a Medicare provider. Please see the graduate students section for more details.


Most Medicaid programs require the licensed CF to enroll directly in the state Medicaid program. Medicaid requirements vary from state to state and among the different state programs. The state Medicaid policies are typically different for outpatient, early intervention, and school billing programs, so it is important for the clinician to check directly with their state’s program.

CFs who are licensed and enrolled with the Medicaid program typically require supervision outlined by the state licensing board for the duration of the fellowship. Some state Medicaid programs may have additional supervision requirements and typically require that the supervising clinician hold a valid state license and be enrolled in the Medicaid program. If a Medicaid program does not allow a CF to enroll, then the program typically has more specific supervision requirements for services provided and documented by CFs. For more details, clinicians should check directly with the program or consult the program’s billing manual. Absent any Medicaid guidance, clinicians should seek permission before billing for services provided by the CF under the supervising clinician’s credentials and NPI number (“incident to” or “under the direction of”)—because this is not always allowed.

Licensed CFs can obtain an NPI and seek enrollment with Medicaid programs. Credentialing and billing requirements vary between programs: Some programs may allow CFs to enroll directly, billing under their own license and NPI, whereas other programs may request that billing be done under the supervisor’s license and NPI. The level of supervision for each CF may vary, depending on how services are billed. Typically, enrolled CFs billing under their own NPI require the supervision outlined by the state licensing board. Clinicians must verify program requirements by checking the state Medicaid program’s website, consulting the provider manual, and/or calling the provider hotline.

Commercial Insurers

Policies by commercial (private) insurers are highly variable; often, different policies can exist under a single insurer, depending on the patient’s specific insurance plan. For example, an employer-sponsored plan could have very different policies from a Marketplace plan from the same insurer. It is important to verify the requirements of each insurance plan being billed. In states with preliminary or conditional licensure for CFs, the billing process is similar for CFs and fully licensed SLPs. Any licensed clinician must obtain an NPI and follow the credentialing procedure determined by each individual payer. Payers expect that licensed and enrolled CFs are supervised in the manner outlined by the state licensing board for the duration of the CF’s fellowship. Commercial payers rarely make additional supervision requirements, but it is important to check. If the CF is not licensed or enrolled as a provider under insurance plans, then they may require 100% supervision—like the requirement for students within outpatient settings. Inpatient settings have some more flexibility, but unlicensed CFs are subject to the student supervision requirements.

When a CF is appropriately enrolled with the insurance plan and is billing under their own license and NPI, CF supervisors do not need to sign all documentation unless required by state law. It is important to note that the act of billing services under another clinician’s credentials is known as “incident to” billing or billing “under the direction of.” This has very strict requirements and is not allowed in many cases, so be sure to check payer requirements before billing for a CF’s services under your credentials. The practice must check with each payer being billed to determine what their requirements are for CF billing.


Please contact ASHA’s health care policy team at for questions related to supervision requirements to maintain billing and payment compliance.


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