Effective Date Policy
All network participation requests must follow the following network effective date policy for all
provider types and for all delegated provider networks.
Policy
Providers will be effective with MDwise either on the first of the month following the receipt of a complete network participation request or the first of the month following the contract execution for brand new providers per the additional guidance below:
For brand-new providers requesting to join the network, once MDwise has received the complete network participation request electronically via an online portal, email, postal mail, or fax and all required fields, supporting documentation provided and signed, the effective date will be the first of the month following the contract execution.
A provider that is being added to an existing contract will be effective the first of the month following receipt of the network participation request from the provider. The network participation receipt date is the date MDwise receives the provider’s complete network participation request electronically via an online portal, email, postal mail, or fax. All required fields must be completed, required supporting documentation provided, etc. for the network participation request to be considered complete.
NOTE: the effective date policy does not affect delegated provider arrangements.
Procedure
The same effective date policy will be in place regardless of whether the network participation request is for a hospital/ancillary provider or a practitioner.
MDwise network effective date will also be after the IHCP effective date. Note: Providers must be enrolled and effective with IHCP prior to being effective with MDwise.
All required fields must be completed, required supporting documentation provided, etc. for the network participation request to be considered complete.
To be able to receive reimbursement for medically necessary covered services, the contract or contract amendment must be executed by both parties.
If a provider’s credentialing decision is not made within 15 days of receipt, the provider will be considered provisionally credentialed until final credentialing decision is made. During the provisional credentialing period, providers will be considered out of network but may start seeing MDwise members.
Providers are expected to complete all pieces of the network participation process timely. However, in instances where the network participation process extends for a-time period longer than the standard timeframe, MDwise will not hold providers to the timely filing limit for claims rendered before the provider was confirmed effective.
The effective date will be the first of the month following the receipt of a complete network participation request or the first of the month following the contract execution for brand new providers, regardless of credentialing completion date. In most cases, the effective date will be retroactive back to the first of the month following receipt of the complete network participation request or the first of the month following the contract execution for brand new providers since providers will not be fully effective until they are credentialed and have a signed contract or contract amendment with the MDwise.
If a provider is unable to be credentialed with MDwise, the provider will not be effective with MDwise.
If MDwise and provider cannot come to terms with a contract, the provider will not be effective with MDwise.
MDwise must reimburse for medically necessary services provided between the date in which the provider was credentialed and the network participation date according to the following rules:
If the provider was fully credentialed without the need for provisional credentialing, the MCE must reimburse to the date in which the provider was fully credentialed.
If the provider was provisionally credentialed and then fully credentialed, the MCE must reimburse back to the date in which the provider was provisionally credentialed.
If the provider was provisionally credentialed but not fully credentialed, the MCE is not required to reimburse for any services during the provisionally credentialed timeframe
For reimbursement of medically necessary services rendered between the credentialing decision date and the network participation date, the MCE will follow IHCP out-of-network reimbursement guidelines for all services.
Services provided before a provider has successfully completed the network participation process are subject to the prior authorization process.
OMPP will allow the MCEs flexibility to deny the provider participation request if the contracting phase cannot be completed in an acceptable timeframe that is no more than 60 days. This will allow the effective date policy to remain consistent but also hold all parties accountable for the turnaround of necessary items for the network participation process. It is important that the MCEs educate providers on the significant impact any delay in signing a contract will have and that if they do not meet the timeframe their request will be denied.
Exceptions to Effective Date
- MDwise may allow for retroactive effective dates in situations such as the following:
- When the retroactive date is in the best interest of member care.
- In situations involving changes of ownership, including provider mergers, acquisitions, or tax identification changes.
- In situations where a provider has a pre-existing contractual relationship with MDwise and has sought a change in their provider enrollment type or classification with the IHCP (i.e., when a provider was enrolled as a Billing provider but has decided to enroll as a Group provider).
- Upon request from federally qualified health centers (FQHCs) or rural health clinics (RHCs).
- An effective date may not be backdated prior to the date enrolled with IHCP.