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Credentialing with Moda Health

Welcome! If you have not yet reviewed our Become a Provider page, please do so before submitting any credentialing materials. If you are not joining an already participating clinic, you must be approved to contract before credentialing materials will be accepted.

Announcement

As part of Moda’s ongoing commitment to a better provider experience, we are pleased to share that we are partnering with symplr CVO to improve our credentialing turnaround times. Moda is augmenting its dedicated, in-house Credentialing team with a new, short-term partnership with Symplr CVO. Symplr will assist Moda by providing Primary Source Verification services on Moda’s behalf. Symplr is a NCQA certified CVO, which assures you of their quality and reliability.

During the processing and verification stages of initial and recredentialing with Moda, symplr may outreach directly to providers on Moda’s behalf. Please respond promptly to any requests to ensure that the process is thorough, timely, and accurate.

This new partnership will allow Moda to work concurrently with symplr and complete all pending applications in a more timely manner, ensuring that providers are credentialed more quickly and effectively.

How to Begin the Credentialing Process

Moda Health utilizes the CAQH ProView as an application source. To begin the credentialing process for a practitioner, please send the provider's first name, last name, and CAQH ID to Credentialing@modahealth.com to prompt the use of CAQH to obtain the application.

Important note: CAQH must reflect that Moda has permission to access this application. The application must be up to date with current attestation status to allow the application to be used. Outdated, or incomplete applications will not be accepted or processed.

If the practitioner does not use CAQH, we also accept credentialing forms submitted directly.

More information on credentialing forms can be found below:

Credentialing forms

Frequently asked questions about credentialing

Is credentialing different than contracting?

Yes. Credentialing and contracting are two separate parts of the practitioner and organizational provider enrollment process. A credentialing approval allows the practitioner or organizational provider to be part of an in-network agreement. Credentialing is required every three years to maintain eligibility. The contracting process is separate and determines the reimbursement rate and in-network status for member plans. Separate lines of business are determined by the contracts negotiated.

What is credentialing?

Prior to allowing network participation, Moda verifies a practitioner's credentials, including but not limited to a valid license to practice, education and training, malpractice history. Information provided within the application will be verified through several entities including the Office of Inspector General, the National Practitioner Data Bank and the appropriate licensing and educational entities.

Do I require credentialing?

What provider type requires credentialing?

Moda requires credentialing for a variety of medical, behavioral health, and alternative care provider types. For a complete list of practitioner types that require credentialing, please see our Moda Practitioner Classification Table. In addition, we also credential organizational providers under the following categories:

  • Hospital
  • Ambulatory surgery center
  • Skilled nursing facility
  • Durable medical equipment (DME) supplier
  • Home health agency / hospice
  • Mental health / chemical dependency / residential treatment facility
  • Eating disorder treatment facilities
  • Birthing center
  • End stage renal disease / renal dialysis
  • Federally qualified health center
  • Comprehensive outpatient rehabilitation facility
  • Rural Health Clinics and Federally Qualified Health Centers
  • Clinical Laboratories

Organizational providers are required to be credentialed at each licensed site that is contracted with Moda.

Hospital based only providers

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.

Locum tenens providers

A practitioner who is new to the Moda 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. Rather, an expedited process will approve credentialing for the locum tenens coverage period. A practitioner may provide locum tenen coverage for a practice once per calendar year.

Does Moda delegate credentialing to other entities?

Yes. We delegate credentialing to other entities within Oregon, Alaska, and Washington, that meet our standards that are based on the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and the Oregon Division of Medical Assistance Programs (DMAP) criteria. Our current delegates include:

Oregon:

  • Oregon Health & Science University
  • Central Oregon Independent Practice Association
  • PrimeCare
  • All Care Independent Practice Association
  • Northwest Rehab Alliance (for physical and occupational therapy)
  • Tuality Health Plan Services
  • Truhearing
  • Providence
  • Legacy
  • Samaritan Health
  • Signify IHA
  • VSP
  • ZoomCare

Alaska:

  • Beech Street Alaska (PHCS/MultiPlan)
  • FirstChoice Health Network
  • Alaska Native Tribe Health Consortium

Washington:

  • FirstChoice Health Network (excluding Clark and Cowlitz counties)
  • Walla Walla Clinic

If you are already credentialed through one of these entities, you may not require direct credentialing with Moda prior to participation. Please email the Moda Health Credentialing team at credentialing@modahealth.com to confirm.

Credentialing requirements

Learn more about Moda's credentialing process to see the criteria for organizational, individual medical, behavioral health and alternative care providers to participate.

Questions?

We're here to help. Please feel free to contact us with any questions or concerns about our credentialing process.

Provider credentialing documentation may be returned via fax, email or regular mail.

Moda utilizes the CAQH ProView site as an application source. Please send the provider's first name, last name, and CAQH ID to Credentialing@modahealth.com to prompt the use of CAQH to obtain the application.

Important note: CAQH must reflect that Moda has permission to access this application. The application must be up to date with current attestation status to allow the application to be used. Outdated, or incomplete applications will not be accepted or processed.

CAQH ProView | CAQH

Toll-free phone number: 855-801-2993
Fax number: 503-265-5707
Email: Credentialing@modahealth.com

Mailing address:
Moda Health
Attn: Credentialing Dept.
601 SW 2nd Ave. #900
Portland, OR 97204

Last updated: Sept 2022

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