What types of providers are eligible for credentialing?
We credential the practitioner and facility types listed below who operate in our service area:
- Physicians–MDs and DOs
- Physician's Assistants
- Advanced Nurse Practitioners
- Nurse Midwives
- CRNAs (Nurse Anesthetists)
- Master's Level Behavioral Health and Licensed Psychologists
- Physical Therapists, Occupational Therapists and Speech Pathology Therapists
- Certified Lactation Consultants
- Registered Dietitians and Nutritionists
- Certified or Licensed Alcohol and Drug Counselors
- Alcohol/Drug Center
- Ambulance Service
- Ambulatory Surgery Centers
- Dialysis Centers
- Durable Medical Equipment
- Home Health Care
- Infusion Therapy
- Physical/Occupational Therapy
- Radiology Center
- Skilled Nursing Facilities
- Sleep Disorder
- Speech Therapy
- Urgent Care
Providers who already are credentialed through a delegated credentialing entity are not required to also be credentialed by Midlands Choice.
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, lactation consultant, registered dietician and nutritionist, certified or licensed alcohol and drug counselor)
How are effective dates assigned?
Application files of practitioners who meet membership criteria are reviewed by our medical director each week. Effective dates generally are Thursdays of the week applications are approved. Applications for providers who do not meet membership criteria are reviewed by our membership credentials committee; participation is effective the day the application is approved. The committee meets on the second Wednesday of each month. Except as required by law for Iowa and South Dakota physicians, we do not backdate applications.
Effective dates are approximately 30 days after committee or clean file approval.
Providers are notified via letter of their application approval and effective date within 10 days of the decision.
How are chiropractors credentialed?
Chiropractors practicing in Nebraska or Iowa should contact one of these organizations to become participating in the Midlands Choice network:
6950 NE 14th St., Ste 34
Ankeny, IA 50023
13215 Birch Dr., Ste 200
Omaha, NE 68164
Chiropractors practicing in other states should Request an Application.
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
- Gundersen Lutheran, Onalaska, WI
- Independent Healthcare Associates, Sioux Falls, SD
- 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
- Nebraska Medicine, Omaha, NE
- Northern Colorado IPA, Greeley, CO
- Northwest Illinois IPA, Freeport, IL
- Paramount Health Options, Cedar Rapids, IA
- Sanford Health System, Sioux Falls, SD
- Trinity PHO, Rock Island, IL
- UniNet Healthcare Network, Omaha & Kearney, NE
- University of Iowa Hospital/Clinics, Iowa City, IA
- University Physicians, Denver, CO
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.
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.
How does Midlands Choice handle Locum Tenens (temporary) arrangements?
Midlands Choice defines Locum Tenens as a provider who provides temporary coverage on behalf of a plan physician for a period of time greater than six weeks and less than six months. Midlands Choice has an expedited credentialing process to allow short-term participation in our network for Locum Tenens providers. If the physician will be providing coverage for longer than six months, the physician would no longer be considered a Locum Tenens provider and must be fully credentialed with Midlands Choice.
If coverage is being provided for less than six weeks, bill for services under the name of the practitioner for whom coverage is being provided. If coverage is being provided for more than six weeks, request an application and complete the process for either a Locum Tenens provider or a fully credentialed provider, depending on how long coverage will be provided.
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.
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, all practitioners are required to maintain and perform to the standards in the office site and medical record review survey criteria and any network provider's office or medical records are subject to review if we receive a patient complaint regarding physical accessibility, physical appearance or adequacy of waiting room and exam room space, quality of care, or as part of our office site/medical record review quality program.
Practitioners must cooperate with all quality improvement activities and allow Midlands Choice the use of practitioner performance data for quality improvement initiatives. Practitioners must also make available to Midlands Choice patients' medical records to process claims and perform necessary quality assurance and quality improvement programs.
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?
- Licensure, including DEA
- Professional liability coverage
- Board certification
- 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
Please note: Midlands Choice does not credential providers with temporary or provisional licensure.
- 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
- Medicare/Medicaid exclusions or sanctions
- Professional liability coverage
- Healthcare Integrity and Protection Data Bank (HIPDB) Reports
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.
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.
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.
Medical specialty listings will be based on education, professional experience and board certification, according to American Board of Medical Specialties standards.