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What do I need to do to credential?

Do I qualify to participate?

Moda follows the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and the Oregon Division of Medical Assistance Programs (DMAP) standards.

Criteria for individual practitioners:

Degree type	Criteria
All individual practitioners	Current, unrestricted state license Completion of graduate program or other required training needed for licensure Free from exclusions and sanctions of federal and state programs Current professional liability insurance with a minimum $1,000,000 per claim and $3,000,000 aggregate amount
MD/DO - Medical / osteopathic physician DPM - Podiatrist	Completion of residency program in designated Specialty, or Board certification in designated specialty
MD/DO - Medical / osteopathic physician DPM - Podiatrist NP - Nurse practitioner	Current hospital affiliation with admitting privileges, or Hospital admit plan that documents the process in the event a member requires hospitalization
MD/DO - Medical / osteopathic physician DPM - Podiatrist NP - Nurse practitioner PA - Physician assistant	Current and valid Drug Enforcement Administration (DEA) certificate in each state where the practitioner provides care to members, or A documented process for allowing a practitioner with a valid DEA certificate to write all prescriptions
MD/DO - Medical / osteopathic physician DPM - Podiatrist NP - Nurse practitioner PA - Physician assistant Behavioral health providers (all types) ND - Naturopath	Call coverage - Contractually required to have participating call share to maintain continuity of care for members

Criteria for organizational providers is as follows:

Facility type	Criteria
All organizational providers	Current, unrestricted state healthcare license, unless not required by the state Note: (Letter / Certificate of Approval from the State in lieu of licensure for Mental Health Accreditation certification from an applicable, recognized accrediting body, or Site survey completed by the state or CMS within the last three years, including all corrective actions Free from exclusions and sanctions of federal and state programs Current professional liability insurance with a minimum of $1,000,000 per claim and $3,000,000 aggregate amount. Note: Higher limits contractually required for hospitals and ambulatory surgery centers
Hospitals Ambulatory surgery centers	Current professional liability insurance with a minimum of $2,000,000 per claim and $5,000,000 aggregate amount

Does Moda need to credential you?

Moda directly credentials organizational and dental providers in-house, and has partnered with Medversant Technologies for credentialing of medical, behavioral health and alternative care individual practitioners.

The individual medical, behavioral health and alternative care practitioner credentialing is as followed:

Initial credentialing	Additional documentation
As written in Senate Bill 507 of the 75th Oregon legislative assembly, Moda Health is required to complete all initial credentialing applications within 90 days upon receipt of a complete application.	Legible copy of your current DEA Certificate (if applicable) Professional liability insurance certificate including limits of liability and expiration date If you are a PA include; state licensing board approved practice description(s) from your supervising physician(s) (describes the duties and functions of the PA in relation to the physician's practice) Seclusion and Restraint Policy as required under (CFR), 438.100 (included within Moda Health Practice Survey)
Re-credentialing (required at least every three years)	Additional documentation
	Legible copy of your current DEA Certificate (if applicable) Professional liability insurance certificate including limits of liability and expiration date If you are a PA include; state licensing board approved practice description(s) from your supervising physician(s) (describes the duties and functions of the PA in relation to the physician's practice) Seclusion and Restraint Policy as required under (CFR), 438.100 (included within Moda Health Practice Survey)

Organizational provider credentialing is as follows:

Facility credentialing

Additional documentation

Application: Organizational Provider Credentialing Application The Organizational Provider Credentialing Application must be completed and submitted with the listed attached documents.

Patient Visitation Policy as required under (CFR), 482.013 (Hospitals only) Completed DMAP Enrollment Form Copy of the most recent State/CMS Site Survey (must be within the last three years) Accreditation information (if applicable) Professional liability insurance certificate including limits of liability and expiration date Seclusion and Restraint Policy as required under (CFR), 438.100 Copy of state license, certificate of approval or letter of approval

What is Moda's credentialing process?

The credentialing process will begin when a complete credentialing application has been received. As written in Senate Bill 507 of the 75th Oregon legislative assembly, Moda Health is required to complete all initial credentialing applications within 90 days upon receipt of a complete application.

Once a completed application is received:

• Primary source verification of all required credentialing elements will be performed.
• The file will be presented to the Medical Director and/or Credentialing Committee for final decision.
• Once the medical director reviews the file, a letter will be sent to the credentialing contact identified in the application informing the provider of the credentialing decision. If needed, the file may be referred to the Moda Health Quality Council for further review at the regularly scheduled meeting.
• Recredentialing is required at least every three years. Moda will begin sending recredentialing packets for organizational providers four months prior to the next credentialing expiration. For individual medical, behavioral health and alternative care practitioners, requests by Medversant Technologies will be sent with instructions on how to complete the recredentialing process.

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