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Credentialing

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Credentialing forms

Individual credentialing for medical, behavioral health and alternative care practitioners will be managed by Medversant Technologies, and all applications should be completed online using ProviderSource™: modahealth.providersource.com.

Locum Tenens Form

A practitioner who is new to the Moda Health panel and provides coverage for an absent practitioner or due to practitioner shortage for a period of 90 consecutive calendar days or less is not required to complete the full credentialing process, but rather an expedited process that will approve credentialing for the Locum Tenens coverage period.

Organizational Provider Credentialing Application and DMAP Enrollment Form

All organizational providers are required to submit a current copy of the Organizational Provider Credentialing Application for both initial and recredentialing of a facility. Credentialing is required at each licensed site of the facility that we will be contracting with.

Along with the credentialing form, we require an updated copy of the DMAP Enrollment Form at each credential instance, in compliance with CMS requirements. You may send a current copy of the form that the facility already has on file, or you may fill out a blank copy that is provided with the credentialing application at each credential instance.

Please note: this is for facility credentialing only.

Hospital Based Enrollment Form

Moda does not credential inpatient setting only practitioners. These are providers who practice exclusively in an inpatient setting and who provide care only as a result of a member's treatment in an inpatient setting. Providers working exclusively in the emergency room of a hospital are considered hospital based, whether providing inpatient or outpatient services.

Provider specialties that fall under this definition per the National Committee for Quality Assurance (NCQA) include: pathology, radiology, anesthesiology, neonatology, emergency medicine and hospitalists.

Please note: Telemedicine providers would not fall under this definition of hospital based, as they are not located within the hospital facility. Full credentialing will be required for this provider type prior to being considered in-network.

Please submit a copy of the Hospital Based Provider Enrollment Form in order to be added to our credentialing and claims systems as hospital based only.

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