Credentialing: What to expect
Credentialing is a multi-step, regulated process that ensures every provider in our network has the education, licenses and training needed to provide care to our members. This process can take 30 to 90 days from receipt of a complete application. Unsolicited applications from providers that are not currently contracted or approved to contract will not be accepted.
Step one: Connect your application to the CAQH portal
Complete the following to initiate credentialing:
- To begin, send the provider's full name, NPI, Tax ID, and CAQH ID to credentialing@modahealth.com. This will prompt the Moda Health system to evaluate your application in CAQH.
- In the CAQH portal, select “Moda Health” as the recipient of your application. This lets our team access it directly. Important: Your application and attestation will remain active in CAQH for 120 days from the day you sign it. After 120 days, we will no longer be able to process your application unless your attestation is resigned.
- Take a moment to double-check the accuracy of your information. This will help avoid any processing delays.
Step two: Stay reachable in case we need you
Once you have completed the steps above, we will begin the credentialing process, which can take from 30 to 90 days. You’ll hear from us during the process if we have any questions, need clarification or need additional information.
What if I don’t use CAQH?
We can also accept the state standardized credentialing applications directly (for providers in Oregon and Texas). Submit your application by email or fax:
Practitioner Rights
Practitioners have rights during the credentialing and recredentialing process and are notified of these rights through various means.
Practitioners have the right to:
- Credentialing and recredentialing decisions that are not based on the practitioner's race, ethnic/national identity, gender, age, sexual orientation or the types of procedures performed (provided such procedures are legal under US law) or patients in which the practitioner specializes.
- Review information the practitioner submitted to Moda Health to support their credentialing application. This may include information obtained from outside sources except for reports from the National Practitioner Databank.
- Correct erroneous information discovered during the verification process. The credentialing specialist will send two written requests to allow the provider to clarify any discrepancy found. Contact information for the credentialing specialist will be provided at the time of the request.
- Request and be informed of the credentialing application status. The credentialing staff will respond to status requests within two weeks of receipt.
- Withdraw, in writing, the application at any time.
- Have the confidentiality of the application and all supporting documents protected and the information used for the sole purpose of application verification, peer review and panel participation decisions, subject to any disclosures required under state or federal law.
- Be notified of these rights.
- Currently credentialed participating providers have the right to appeal application termination decisions and adverse actions taken by Moda Health, as outlined in the Appeal of Moda Health Adverse Action policy. Providers who are not currently credentialed are not eligible to appeal under this policy.
Practitioners are notified of their rights in the Moda Health participating provider administrative manuals.
Questions?
For questions about credentialing, you can reach out to the credentialing team at 855-801-2993 or credentialing@modahealth.com.