For Healthcare Providers:

Application Checklist

Before we can begin the credentialing process, we must have a complete application. Incomplete applications will be held for 15 days, then removed from consideration, if we do not receive all required information.

Applicants are also responsible for producing current, accurate and sufficient information for evaluation of qualifications and for updating any information that changes during review.

Requirements for all providers:

  • All questions answered on the application
  • Explanations of any affirmative responses on the questionnaire
  • Proof of current liability insurance in required amounts
  • Signed release allowing Midlands Choice to verify credentials
  • Signed and dated application attestation
  • National Provider Identifier (NPI) numbers

Additional requirements for practitioners:

  • Education and work history, with explanations for any gaps of six months or more
  • Copy of current federal controlled substance certificate or waiver, if applicable
  • Copy of current state controlled substance certificate or waiver, if applicable

Additional requirements for facilities:

  • Copy of current state license registration certificate
  • Documentation of accreditation through TJC, CARF, AAAHC, CCAC or similar accreditation organization
  • Medicare/Medicaid number and a copy of most recent Medicare and Medicaid surveys or letter approving participation
  • For hospitals, a list of hospital-based providers (e.g. emergency room physicians,pathologists, radiologists and anesthesiologists) for whom charges will be submitted
  • For medical laboratories, a copy of current CLIA Certificate of Accreditation, compliance, registration or waiver
  • For radiology facilities, copies of current state and federal radiology licenses, permits, registrations or certifications for x-ray emitting equipment, mammography and nuclear medicine. Radiology facilities must be accredited by either the American College of Radiology (ACR) and/or the Intersocietal Accreditation commission (IAC) in the following areas to be eligible for membership: Magnetic resonance imaging (MRI), Magnetic resonance angiography (MRA), Computed tomography (CT), Echocardiograms, Nuclear medicine imaging such as Positron emission tomography (PET) and Single photon emission computed tomography (SPECT). The accreditation requirement is not applicable for facilities that provide services solely for X-ray, ultrasound, fluoroscopy and mammography.