Moda Health medical provider contracting request

Thank you for your interest in becoming a participating provider in the Moda Health network.

Contracting and credentialing are two separate processes that together provide In-Network status. Credentialing is the verification of specialties, education, and liability insurance. Contracting is the discussion of reimbursement rates and network participation. Being actively credentialed and contracted is the only way a practitioner can see Moda members as an In-Network provider.

To direct your request appropriately, please review the following scenarios and follow the instructions that apply to your request:

Providers Joining an Already Contracted Clinic

If you are joining a clinic that is already contracted with us, you do not need to review the following. Instead, please complete an Oregon credentialing application now. Once credentialing is completed, you will be given instructions on how to be added to the existing contract.
Credentialing applications must be submitted it to the Credentialing department by email, fax or regular mail.
Email: credentialing@modahealth.com
Fax: 503-265-5707
Mailing address:
Moda Health
Attn: Credentialing Dept.
601 SW 2nd Ave. #900
Portland, OR 97204
Existing Providers:
1. If you are a currently credentialed provider who is seeing Moda patients and you are leaving your existing clinic to contract under a new Tax ID, please complete the Existing Provider Contracting Request. Please note, contract requests will be reviewed and responded to within 20 business days. Providers that submit a request that do not fit the criteria as outlined above will not be responded to.
2. If you are currently contracted through Idaho Physicians Network (IPN) and are seeking a direct contract with Moda Health due to the IPN termination, please complete the Existing Provider Contracting Request. Please note, direct contracts are only being offered to providers located in Ada, Adams, Canyon, Gem, Idaho, Owyhee, Payette and Washington counties. No requests will be accepted after 6/30/2022.
New Providers:

If you are a brand-new provider that is not currently credentialed with Moda Health and not joining an already contracted group, review the nominations panel below.

Our Oregon, Washington, and Idaho panel is currently closed to new providers with the exception of Diversity, Equity, & Inclusion (DEI) providers. Our panel is reviewed bi-annually and will be updated in December 2022. If the panel is not open in your area at this time, please do not complete a credentialing application. We do not accept unsolicited credentialing applications for providers who have not been approved for participation via a Contract Request.

Check the panel now

Nominations Panel - Oregon
Category	Specialties	County Status
Diversity, Equity & Inclusion (DEI) Providers NOTE: use the DEI Provider Contract request form	Providers who identify as or provide: Black/African American Centered Care Hispanic and Latinx Centered Care Indigenous/Native American Centered Care Asian and Pacific Islander Centered Care LGBTQIA+ Centered Care Sensory Disability Centered Care Intellectual and Developmental Disability Centered Care Veteran Centered Care Bilingual Care Culturally Specific Care Gender Affirming Care	Open Counties: All Counties
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Closed Counties: All Counties
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Marriage/Family Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Closed Counties: All Counties
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Closed Counties: All Counties
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Closed Counties: All Counties
All Other Specialties	All	Closed Counties: All Counties
DME	All	Closed Counties: All Counties
Lab	All	Closed Counties: All Counties
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Closed Counties: All Counties

Nominations Panel - Washington
Category	Specialties	County Status
Diversity, Equity & Inclusion (DEI) Providers NOTE: use the DEI Provider Contract request form	Providers who identify as or provide: Black/African American Centered Care Hispanic and Latinx Centered Care Indigenous/Native American Centered Care Asian and Pacific Islander Centered Care LGBTQIA+ Centered Care Sensory Disability Centered Care Intellectual and Developmental Disability Centered Care Veteran Centered Care Bilingual Care Culturally Specific Care Gender Affirming Care	Open Counties: Benton Clark Cowlitz Walla Walla
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Closed Counties: All Counties
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Marriage/Family Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Closed Counties: All Counties
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Closed Counties: All Counties
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Closed Counties: All Counties
All Other Specialties	All	Closed Counties: All Counties
DME	All	Closed Counties: All Counties
Lab	All	Closed Counties: All Counties
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Closed Counties: All Counties

Nominations Panel - Idaho
Category	Specialties	County Status
Diversity, Equity & Inclusion (DEI) Providers NOTE: use the DEI Provider Contract request form	Providers who identify as or provide: Black/African American Centered Care Hispanic and Latinx Centered Care Indigenous/Native American Centered Care Asian and Pacific Islander Centered Care LGBTQIA+ Centered Care Sensory Disability Centered Care Intellectual and Developmental Disability Centered Care Veteran Centered Care Bilingual Care Culturally Specific Care Gender Affirming Care	Open Counties: Adams Ada Canyon Gem Owyhee Payette
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Closed Counties: All Counties
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Family/Marriage Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Closed Counties: All Counties
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Closed Counties: All Counties
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Closed Counties: All Counties
All Other Specialties	All	Closed Counties: All Counties
DME	All	Closed Counties: All Counties
Lab	All	Closed Counties: All Counties
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Closed Counties: All Counties

*The nominations panel was updated in February 2022 and is reviewed on a bi-annual basis

Check the panel now

Nominations Panel - Alaska
Category	Specialties	Burrough Status
Diversity, Equity & Inclusion (DEI) Providers NOTE: use the DEI Provider Contract request form	Providers who identify as or provide: Black/African American Centered Care Hispanic and Latinx Centered Care Indigenous/Native American Centered Care Asian and Pacific Islander Centered Care LGBTQIA+ Centered Care Sensory Disability Centered Care Intellectual and Developmental Disability Centered Care Veteran Centered Care Bilingual Care Culturally Specific Care Gender Affirming Care	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Family/Marriage Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
All Other Specialties	All	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
DME	All	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Lab	All	Closed Burroughs: All Burroughs
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell

*The nominations panel was updated in December 2021 and is reviewed on an annual basis.

Interested in joining our provider network? Please complete and submit the new provider network participation request form below. Note:

If you have not already reviewed our nominations panel, please do so before submitting the new provider network participation request form.

Check the panel now

Nominations Panel - Alaska
Category	Specialties	Burrough Status
Diversity, Equity & Inclusion (DEI) Providers NOTE: use the DEI Provider Contract request form	Providers who identify as or provide: Black/African American Centered Care Hispanic and Latinx Centered Care Indigenous/Native American Centered Care Asian and Pacific Islander Centered Care LGBTQIA+ Centered Care Sensory Disability Centered Care Intellectual and Developmental Disability Centered Care Veteran Centered Care Bilingual Care Culturally Specific Care Gender Affirming Care	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Family/Marriage Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
All Other Specialties	All	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
DME	All	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Lab	All	Closed Burroughs: All Burroughs
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell

*The nominations panel was updated in December 2021 and is reviewed on an annual basis.

*Specialty:
*Licensed to Practice In (check all that apply): Alaska Oregon Washington Idaho Texas None
*County:
*Burrough:
*Provider name:
*Licensure:
*Current Clinic Name:
*Current Clinic Tax ID:
*Current Clinic Address:
*Date Leaving/Left Clinic (if applicable):
*New Clinic Name:
*New Clinic Tax ID:
*New Clinic Address:
*Starting Date with New Clinic:
*Business/Provider name:
*Tax ID:
*Type 1 NPI (Individual - if applicable):
*Type 2 NPI (Organizational - if applicable):
Medicare Eligible:
Yes No
Medicare PTAN number:
Medicaid Eligible:
Yes No
Medicaid DMAP number:
*New Clinic Primary Address:
Primary Address Line 2 (optional):
*New Clinic City:
*New Clinic State:
*New Clinic Zip Code:
*Provider first/last name:
*Primary Address:
Primary Address Line 2 (optional):
*City:
*State:
*Zip Code:
*Provider contact first/last name:
*Provider email:
*Office/Contracting first/last name:
*Office/Contracting email:
*Phone number:
Fax:
Notes, description of services:

^{*Required field}
Are you a behavioral health provider?
Yes No
Are you currently seeing any Moda members?
Yes No
Are contracted providers referring our members to you?
Yes No
Are you requesting to be a Primary Care Provider (PCP)?
Yes No
If, yes please provide the following information:
Are you a patient centered medical home?
Yes No
Are you able to provide 24/7 coverage for members?
Yes No
Are you able to provide pharmaceutical management to members with chronic conditions?
Yes No

Provider network participating request form - Oregon Alaska

Providers Joining an Already Contracted Clinic

Existing Providers:

New Providers:

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Contracting Request Form for Existing Providers

New provider network participation request form

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Provider network participating request form - Oregon Alaska

Providers Joining an Already Contracted Clinic

Existing Providers:

New Providers:

Check the panel now

Check the panel now

Check the panel now

Contracting Request Form for Existing Providers

New provider network participation request form

Moda Health Provider Network

Opt in for medical

Member Dashboard

Questions?

Questions?

Employer web tools

Benefit Tracker

Provider Reports

Join our email list

Benefit Tracker

Producer web tools

Privacy alert

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