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Credentialing

The information on this web page is intended for practitioners and facilities in the MVP service area.  This area includes most of New York State, Vermont and New Hampshire.  Please refer to the MVP Service Area maps to determine if you are within the MVP service area. Practitioners outside of the area may provide services to MVP members via the CIGNA national network. How to join the CIGNA Network.

 

Credentialing FAQs

Q:  Who needs to be credentialed?
A:  Physicians (see exceptions under Practitioner Registration), oral surgeons, podiatrists, optometrists, audiologists, physical therapists, occupational therapists, speech/language pathologists, certified nurse midwives, certified diabetes educators, and behavioral health practitioners. There are additional credentialing requirements, specific by state, for naturopaths and athletic trainers (Vermont only), independent nurse practitioners (New York only), and advanced practice registered nurses (Vermont and New Hampshire only). In addition, certain facility types must also undergo credentialing. They are ambulatory mental health and substance abuse treatment facilities, adult day health care centers (NY only), HIV/AIDS day care centers (New York only), bariatric surgery centers, federally qualified health care centers, free-standing ambulatory surgery centers, free-standing birthing centers (New Hampshire only), free-standing dialysis centers, free-standing radiology centers, free-standing rehabilitation centers (mental rehab and physical rehab only), home health/infusion agencies/home health agencies providing personal care assistant services), hospice, hospitals, hyperbaric medicine treatment centers, long-term care facilities, portable/mobile x-ray suppliers, psychiatric hospitals, residential alcohol/substance abuse treatment facilities, skilled nursing facilities, transplant programs, and urgent care centers.

 

Important: Chiropractors, acupuncturists and massage therapists are contracted and credentialed through a delegation agreement with Landmark Health Care.  Please go to Landmark Health Care for additional information.

 

All behavioral health practitioners and behavioral health facilities located outside of Vermont are contracted and credentialed through a delegation agreement with ValueOptions®. Click here for more information about ValueOptions®.  

 

Please note that contracting and credentialing of healthcare practitioners may be limited by geographic need.

 

Q: How do I apply?
A:  All practitioners who require credentialing must complete the online Coalition for Affordable Quality Health Care (CAQH) Universal Credentialing Application®. To get started please do the following:

  • Determine if you already have a CAQH provider ID number.

  • Determine if you are joining an existing contract or will require a new contract.

  • Contact MVP Professional Relations at 1-888-363-9485 to be directed to the appropriate Professional Relations Representative in your area.

  • Provide your Professional Relations Representative with your CAQH provider ID number by calling 1-888-363-9485. Exception: West Region (Rochester/Buffalo): Regardless whether you have a CAQH provider number, please complete the CAQH Provider Data Form and fax it to 585-327-2289 to begin the credentialing process. A CAQH provider number will be sent to you if you don’t already have one.

  • If you will need a contract, please complete and return a Federal W-9 form.

  • Complete or update your CAQH online application.  To access your application please visit https://upd.caqh.org/oas/. Be sure that you have listed MVP as an authorized plan. For assistance with completion of the CAQH application please contact the CAQH Help Desk at 1-888-599-1771 or email your question to caqh.updhelp@acsqs.com.

  • Click here for more information on getting started with CAQH.

  • Click here for more CAQH application tips.

Important:  If you already have a CAQH number you must communicate that number and your desire to join MVP via the Professional Relations Department in your region or, in the Rochester/Buffalo area, by completing and faxing your CAQH Provider Data Form to 585-327-2289. MVP must add your name to their CAQH provider roster. Just adding MVP to the list of authorized plans on your CAQH application will not result in a request to be credentialed with MVP. In addition, completion of the CAQH application does not grant participation or constitute approval for network participation.

 

Q:  When will credentialing process begin?
A:  The credentialing process will not be started until MVP has been given access to a complete CAQH application (including current documentation of adequate malpractice insurance, current licensure etc.) and the applicant has returned a signed contract (if applicable). Once the application has been determined to be complete, the Credentialing Staff will begin primary source verification of education, licensure, training etc.) as per state and federal regulations.

 

Q:  When does the credentialing process end?
A:  The process is completed when all elements required by state and federal law have been verified and all required queries are complete. At that time, the file will be presented to the Credentials Committee for review and decision.

Important: Credentialing applicants are not authorized to provide services to MVP members until they have been reviewed and approved by the MVP Credentials Committee.  Practitioner effective dates will not be made retroactive prior to the Credentials Committee approval date.

 

Miscellaneous Credentialing Information

  • All practitioners are required to meet the minimum criteria for their specialty.  Criteria are available by contacting the MVP Credentialing Department at 888-363-9485. View general credentialing criteria.

  • New practice offices/locations for primary care physicians (PCPs) and OB/GYNs may be required to undergo a practice site inspection, including a review of medical record keeping practices.

New York State Physicians Requesting HIV/AIDS Specialty Designation:

Per the New York State Department of Health (NYS DOH), health plans are required to identify those physicians who have identified themselves as HIV/AIDS Specialists and to list those physicians in MVP Directories.  Following the NYS DOH criteria, MVP has created an “Identification and Notification of HIV/AIDS Specialist Attestation Questionnaire” which physicians may complete and return to the MVP Credentialing Department.  Physicians who return the completed form and are found to meet the NYS DOH criteria, will be listed in MVP directories under the additional specialty of HIV/AIDS Specialist.   

Practitioner Rights

All practitioners have the following rights:
  • The right to review information received in support of their credentialing application.

  •  Applicants have the right to review the information obtained from any outside primary source that is presented to the Credentials Committee in support of their credentialing and/or recredentialing application. For example, malpractice insurance carriers, state licensing boards, and hospitals. Recommendations, letters of reference and other peer review protected information are not subject to this disclosure. (Note: Disclosure of NPDB documentation can only be released directly to the Practitioner.)

  • Upon receipt of an applicant’s written, signed and dated request, MVP will release under confidential cover to the applicant by Delivery Confirmed or Certified Mail, Return Receipt Requested the information that is presented to the Credentials Committee in support of their credentialing/recredentialing application.

  • The right to correct erroneous information submitted during the credentialing/ recredentialing process. Should the Credentialing Staff receive information that differs substantially from the information provided by the practitioner, a member of the Credentialing Management staff will notify the practitioner, in writing, of the discrepancy.

  • The right to be informed of their credentialing or recredentialing application status. MVP Health Care, upon applicant’s direct verbal or written request, will notify him/her of the status of their application.

Provisional Credentialing of NYS Physicians

Per NYS law, New York State Applicants that are joining a participating group in which all members of the group already currently participate with MVP Health Care are eligible for provisional credentialing as of the 91st day of the application process in the following circumstances:

  1. You have submitted a completed application along with any requested supporting documentation;
  2. You have submitted a written request for provisional credentialing to the MVP Health Care Associate Director of Credentialing and stated that should your application be denied, you or your group practice:
    • shall refund any payments made for in network services provided during the period of provisional credentialing that exceed out of network benefits under the insured's contract with MVP Health Care; and
    • shall not pursue reimbursement from the insured, except to collect the co-payment or coinsurance that otherwise would have been payable had the insured received services from a participating MVP provider.

Practitioner Registration

The following practitioner types do not require credentialing but must be registered: Hospitalists (Internal Medicine, Pediatric or Family Medicine), Emergency Department Physicians, Pathologists, Anesthesiologists, Neonatologists, Certified Registered Nurse Anesthetists, Nurse Practitioners, Registered Dieticians, Registered Nutritionists and Physicians Assistants. Download the Registration Form .

 

Exceptions:  Anesthesiologists who want to be designated as Pain Treatment specialists or Hospitalist physicians (other than Pathologists) who also work outside of the inpatient setting must be credentialed.

 

Demographic Changes for Credentialed Practitioners:

All demographic changes are handled by the Professional Relations Department at 1-888-363-9485 or complete and return the Provider Change Form located in the Provider Forms section.

 

Facility Credentialing

Facilities and organizations who wish to participate with MVP Health Care, call 1-877-736-5735. Upon commencement of the contracting process, Network Management will provide the facility with an “Application for Participation for MVP Health Care Organizational Providers” form for completion and return. View facility credentialing criteria.

 

Urgent Care Centers and Anesthesiology groups providing anesthesia for office-based surgery are required to submit a hospital transfer protocol to verify how they intend to ensure timely and adequate communications with the receiving hospital and PCP in the event a patient requires emergent transfer to a hospital.  A copy of the protocol should be submitted with the completed Hospital Transfer Protocol Cover Sheet.

 

Contact the MVP Health Care Credentialing Staff

To contact a member of the MVP Health Care Credentialing, please call 1-888-363-9485.