Credentialing Requirements

Credentialing Requirements

Submission of a completed applicable IHCP MCE Enrollment Form initiates the MDwise Credentialing process. A provider network participation request is considered complete when all required fields are populated, and all applicable supporting documents are included in the submission. All eligible provider types and specialties must be actively enrolled with IHCP and linked to their requested service location prior to submitting a network participation request to MDwise. Participation document requirements are based on provider type according the IHCP Specialty Matrix.

Per IHCP requirements, MDwise must credential providers before permitting those providers to bill claims for services to IHCP members.

MDwise initial credentialing, and recredentialing process includes a visit to the offices of all potential primary medical providers (PMPs), including all obstetricians and gynecologists (OB/GYNs) to ensure conformity with the maintenance of medical records, quality of care and service issues including terminating the provider’s participation with MDwise. Policies and procedures must have mechanisms in place for reporting serious quality deficiencies to the State that could result in a provider’s suspension or termination. The initial site visit must document evaluation of the medical recordkeeping practices at each site. MDwise requires providers to comply with the completion of the site visit within a reasonable timeframe from the initial request not to exceed five (5) business days. Failure to comply with timely completion of the site visit will delay credentialing and cause an adverse impact to provider enrollment.

MDwise is required to credential the following providers:

  • Licensed independent medical and behavioral health practitioners or groups of practitioners (including non-physician practitioners) who are contracted with and have an independent relationship with MDwise and provide care for MDwise members.
  • Practitioners who see members outside the inpatient hospital setting or outside freestanding ambulatory or facility-based settings.
  • Oral surgeons who provide care under the medical benefit.
  • Nonphysician practitioners who have an independent relationship with MDwise and who provide care under the medical or behavioral health benefit (e.g., nurse practitioners, clinical nurse specialists, and physician assistants).

Providers that do not require Credentialing:

  • Not all provider types require credentialing prior to being approved through the Provider Network Participation Process. The below provider types and scenarios are excluded from the MDwise Credentialing Process:
    • Practitioners who practice exclusively within the inpatient setting and provide care for MDwise members only because of members being directed to the hospital or other inpatient setting (e.g., pathologists, radiologists, emergency room physicians, etc.).
    • Practitioners who practice exclusively within freestanding facilities and who provide care for MDwise members only because of members being directed to the facility (e.g., urgent care centers, surgery centers, etc.).
    • Pharmacists who work for a pharmacy benefits management organization to whom MDwise delegates medical management activities.
    • Practitioners who do not care for members in a treatment setting (e.g., board-certified consultants).
    • Covering practitioners (e.g., locum tenens).