Credentialing FAQs

Providers who already are credentialed through a delegated credentialing entity are not required to also be credentialed by Midlands Choice. back to top

What are your Level I and Level II network participation criteria for practitioners, hospitals and facilities?

Practitioners (MD and DO, podiatrist, chiropractor, optometrist, nurse practitioner, physician assistant, psychologist, master's level behavioral health, physical therapist, occupational therapist, speech therapist, audiologist)
Hospitals
Facilities back to top

How are effective dates assigned?

For individual practitioners, the effective date is the day participation is approved by our credentialing committee, which meets on the second Wednesday of each month. For facilities, the effective date is approximately 30 days after committee approval. Providers are notified via letter of their application approval and effective date.

Except as required by law for Iowa physicians, we do not backdate applications. back to top

How are chiropractors credentialed?

To be part of the Midlands Choice network, chiropractors should contact one of these organizations:

ICPC
6950 NE 14th St., Ste 34
Ankeny, IA 50023
(515) 225-0393
E-mail

Pinnacle Physicians Network
13215 Birch Dr., Ste 200
Omaha, NE 68164
(402) 934-4744
E-mail

Advantage Chiropractic Network
100 E. Grand Ave., Ste. 240
Des Moines, IA 50309
(515) 867-2806
E-mail

Chiropractic Associates of South Dakota and Minnesota
2301 Research Park Way, Ste. 221
Brookings, SD 57006
(800) 658-2214 back to top

If a practitioner is already credentialed by an IPA or PHO, does he or she also need to be credentialed by Midlands Choice?

We have relationships with 17 IPAs and PHOs to whom we have delegated credentialing responsibilities for practitioners with whom they contract. Additional credentialing by Midlands Choice is not required. The IPAs and PHOs are:

Avera Health Network, Sioux Falls, SD
Avera Tri State Health Physicians/Allied Health, Sioux Falls, SD
Cedar Rapids PHO, Cedar Rapids, IA
Medical Associates of Dubuque, Dubuque, IA
Medimore, Des Moines, IA
Mercy Hospital North IA, Mason City, IA
Mercy Iowa City PHO, Iowa City, IA
Methodist Health Partners, Omaha, NE
Northern Colorado IPA, Greeley, CO
Northwest Illinois IPA, Freeport, IL
Sanford Health System, Sioux Falls, SD
Sentinel Health Care, Kearney, NE
Trinity PHO, Rock Island, IL
UniNet, Omaha, NE
University of Iowa Hospital/Clinics, Iowa City, IA
University Physicians, Denver, CO
UNMC Physicians, Omaha, NE back to top

What are practitioners' contracting options (individual, group, etc.)?

We credential each practitioner individually, but practitioners may contract with Midlands Choice individually, as part of a group, through an IPA or PHO, or through multiple contracts. Because claims must be submitted with the tax identification number of the contracted entity, practitioners who anticipate billing under a separate tax identification number must contract individually.

Providers who contract with Midlands Choice through a group, IPA, or PHO that is enrolled under a delegated credentialing arrangement must be re-credentialed upon leaving the contracted entity if they want to continue as network providers. Their in-network status continues during the re-credentialing period. Notifying Midlands Choice when practitioners join or leave a group or independently contracted practice is the responsibility of the contracted entity.

When a hospital, facility or group practice adds or relocates a service such as urgent care, physical therapy or an imaging center, additional credentialing, and possibly additional contracting, are required if claims will be submitted under a separate tax identification number. back to top

What is the make-up of the credentialing committee?

Members of the committee are current Midlands Choice network providers from a variety of practice disciplines and specialties. Because evaluation of provider credentials requires objective assessment of qualifications and other relevant information, members of the credentialing committee who are partners, associates, relatives, employees, employers, or in direct economic competition, will abstain from participation in the credentialing process if the member believes participation represents a conflict of interest. back to top

How does Midlands Choice handle Locum Tenens (temporary) arrangements?

Locum Tenens is defined as a provider who provides coverage for a network provider during a temporary absence of up to to six months. If you have any questions about participating as a Locum Tenens provider, contact Contracting.

If coverage will be provided for less than six weeks, bill for services under the name of the practitioner for whom coverage is being provided. If coverage will be provided for more than six months, you are not a Locum Tenens provider and must request an application and complete the process to become a participating network provider. back to top

How does Midlands choice handle credentialing for new graduates?

For physicians completing residencies or fellowships, application requirements are the same as for any provider. However, provisional status can be granted once for up to 60 days while hospital privileges and education are verified. back to top

What are the steps in the credentialing process?

Step 1: Request an application.

Step 2: For facilities, we schedule review by our contracting committee to determine whether they may proceed with submitting an application; this step is not required for practitioners.

Step 3: You will receive an application and supporting documents by mail. Complete the application, review the Application Checklist, then submit your application.

Step 4: Our credentialing staff verifies credentials and prepares applicants' files for review by the credentialing committee. Office site surveys are no longer required during initial credentialing for primary care providers or Ob/Gyn specialists prior to committee review. However, any network provider's office is subject to review if we receive a patient complaint regarding physical accessibility, physical appearance or adequacy of waiting room and exam room space, or as part of our office site/medical record review quality program.

Step 5: The credentialing committee, which meets on the second Wednesday of each month, determines whether the application is approved or denied. We will notify you of the committee's decision.

Office Site Review Criteria:

What information is verified during the application review?

For practitioners:

Licensure, including DEA
Professional liability coverage
Board certification
Education/training
Professional liability claim history
Medicare/Medicaid exclusions or sanctions
Work history
National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank (HIPDB) Reports

For facilities:

Licensure, including DEA
Documentation of accreditation by TJC, CARF, AAAHC or CCAC or similar accrediting organization, or participation in Medicare/Medicaid
Professional liability claims history
Complaints
Medicare/Medicaid exclusions or sanctions
Professional liability coverage
Healthcare Integrity and Protection Data Bank (HIPDB) Reports back to top

What is the function of the facility contracting committee?

Requests from facilities to join the network are evaluated by the contracting committee, which meets quarterly. In evaluating the facility's request, the committee reviews such factors as:

Requests from payer partners and employer groups for specific providers or services in our service area
Applicants' potential to reduce patient waiting times, increase access to services (including rural areas), reduce travel time or provide services for lower fees than current providers
Applicants' referral relationships with current providers
Potential for applicants' network membership to enhance Midlands Choice cost effectiveness through preferential pricing, minimization of administrative costs, and effective medical/practice management
Applicants' participation in competitor networks
Potential to help Midlands Choice and its business partners build and implement new healthcare delivery products

If the request is approved, the facility may submit a credentialing application. If the request is not approved, the facility will be notified of the reasons for the decision and may appeal for reconsideration. Appeal procedures are outlined in the letter notifying the provider of the contracting committee's decision.

Contact Contracting if you have questions about the process for being considered for network participation by the contracting committee. back to top

What are providers rights during the credentialing process?

Applicants have the right to review the information we gather during application processing, to ask about the status of your application while it is in process, and to correct any information submitted by another party you feel is incorrect.

Information we gather during application processing includes information that we have obtained from outside primary sources such as malpractice insurance carriers or state licensing boards. By law, we are not allowed to release information submitted to the National Practitioner Data Bank, or information that is considered to be peer-review protected.

During the credentialing process, if we receive information that varies significantly from information submitted on the application, we will provide an opportunity to explain the discrepancy. back to top

Can the credentialing committee's decision be appealed?

Yes. Procedures for appealing the credentialing committee's decision are outlined in the letter notifying the provider of the credentialing committee's decision. back to top

When are new providers listed in the directory?

New providers will be listed in the on-line provider directory within 10-15 business days of the contract effective date and in the printed directory as production schedules allow.

Medical specialty listings will be based on education, professional experience and board certification, according to American Board of Medical Specialties standards. back to top

For Healthcare Providers