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Pathway to provider participation

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
  • Birthing center
  • End stage renal disease / renal dialysis
  • Federally qualified health center
  • Comprehensive outpatient rehabilitation facility

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.

Does Moda delegate credentialing to other entities?

Yes. We delegate credentialing to other entities within Oregon, Alaska, Washington, Idaho and California 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
  • Mid-Rogue Independent Practice Association
  • Northwest Rehab Alliance (for physical and occupational therapy)
  • Tuality Health Alliance
  • Providence
  • ZoomCare

Alaska:

  • Beech Street Alaska (PHCS MultiPlan)

Washington:

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

Idaho:

  • IPN
  • Saint Alphonsus / SARMC
  • St. Lukes / UHC

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 to confirm.

Credentialing forms

Individual credentialing for medical, behavioral health and alternative care practitioners are managed by Moda Health.

Locum Tenens Form

A practitioner who is new to the 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 credentialing 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.

Credentialing requirements

Want to learn more about Moda's credentialing process? Click here 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.

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

Toll-free phone number: 855-801-2993

Fax number: 503-265-5707

Email:

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

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