What types of providers are eligible
for credentialing?
We credential the practitioner and facility types listed below who operate in our service area:
Practitioners:
- Physicians–MDs and DOs
- Podiatrists
- Optometrists
- Physician's Assistants
- Advanced Nurse Practitioners
- Chiropractors
- Nurse Midwives
- CRNAs (Nurse Anesthetists)
- Master's Level Behavioral Health and Licensed Psychologists
- Physical Therapists, Occupational Therapists and Speech Pathology Therapists
- Audiologists
- Certified Lactation Consultants
- Registered Dietitians and Nutritionists
- Specialty Dentist
- Applied Behavior Analyst
- Certified or Licensed Alcohol and Drug Counselors
- Genetic Counselors
Hospital Types:
- Acute Care
- Children's - General
- Children's - Rehab
- Critical Access
- Psychiatric
- Specialty
- Tertiary
Facility Types that are Credentialed:
- Alcohol and Drug Center
- Ambulatory Surgical Center
- Birthing Center
- Cancer Center
- Cardiac Monitoring
- Cath Lab
- Community Mental Health
- Diagnostic Center
- Emergency Room
- Endoscopy Center
- Home Health Care
- Hospice
- Home Infusion Therapy
- Independent Lab
- Magnetic Resonance Imaging Center
- Maternal Home Health
- Nutrition
- Public Health
- Radiation Therapy
- Radiation (X-Ray)
- Rehabilitation
- Skilled Nursing Facility
- Sleep Disorder
- Wound Care
Facility Types that are not Credentialed, but are added as "Claims or Directory Only":
- Ambulance
- Audiology
- Breast Prosthesis/Mastectomy Products
- Diabetes Education
- Diabetic Supplies
- Durable Medical Equipment
- Durable/Home Medical Equipment
- Health Care Products
- Orthotics/Prosthetics Supplier
- Physical and Occupational Therapy
- Physical Therapy
- Physical Therapy/Rehabilitation
- Urgent Care Center
- Walk in Clinic
- Vision Hardware
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, genetic counselor)
Hospitals
Facilities
How are effective dates assigned?
Practitioners
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.
Facilities
Effective dates are approximately 45 days after committee or clean file approval.
Notification
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:
ICPC
6950 NE 14th St., Ste 34
Ankeny, IA 50023
(515) 225-0393
E-mail
SecureCare
13215 Birch Dr., Ste 200
Omaha, NE 68164
(402) 934-4744
E-mail
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 19 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, Omaha, Sioux Falls, SD
- CHI Health Partners, Omaha, Kearney, and Lincoln, NE
- Children's Hospital and Medical Center, Omaha, NE
- Gundersen Lutheran, Onalaska, WI
- ICPC, Ankeny, IA
- 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 Health Partners, Omaha, NE
- Northern Colorado IPA, Greeley, CO
- Northwest Illinois IPA, Freeport, IL
- Paramount Health Options, Cedar Rapids, IA
- Sanford Health, Sioux Falls, SD
- Secure Care, Omaha, NE
- University of Iowa Hospital/Clinics, Iowa City, IA
- University of Colorado Medicine/CU Medicine, 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 via Midlands Choice website.
Step 2: You will update the CAQH application for providers or receive an application by email for
Facilities. Complete the application, review the Application Checklist, then
submit your application.
Step 3: 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 4: 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 Reports
Please note: Midlands Choice does not credential providers with temporary or provisional
licensure.
For facilities:
- Licensure, including DEA
- Documentation of accreditation by TJC, CARF, AAAHC or CCAC or similar accrediting organization, or
participation in Medicare/Medicaid
- Radiology facilities providing advanced diagnostic imaging procedures must be accredited by the
American College of Radiology (ACR), or the Intersocietal Accreditation Commission (IAC) or The
Joint Commission (TJC)
- Professional liability claims history
- Complaints
- Medicare/Medicaid exclusions or sanctions
- Professional liability coverage
- National Practitioner Data Bank
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.