Credentialing with Moda Health
Welcome! If you have not yet reviewed our Become a Provider page, please do so before submitting any credentialing materials. If you are not joining an already participating clinic, you must be approved to contract before credentialing materials will be accepted.
How to Begin the Credentialing Process
Moda Health utilizes the CAQH ProView as an application source. To begin the credentialing process for a practitioner, please send the provider's first name, last name, and CAQH ID to Credentialing@modahealth.com to prompt the use of CAQH to obtain the application.
Important note: CAQH must reflect that Moda has permission to access this application. The application must be up to date with current attestation status to allow the application to be used. Outdated, or incomplete applications will not be accepted or processed.
If the practitioner does not use CAQH, we also accept credentialing forms submitted directly.
More information on credentialing forms can be found below:
Credentialing forms
- Oregon Practitioner Credentialing Application Alaska Practitioner Credentialing Application - Individual credentialing for medical, behavioral health and alternative care practitioners.
- Organizational Provider Credentialing Application - All organizational providers are required to submit a current copy of the Organizational Provider Credentialing Application for both credentialing and recredentialing of a facility. Credentialing is required at each licensed site of the facility that we will be contracting with. Please note that this is for facility credentialing only.
- Locum Tenens Form- A practitioner who is new to the panel and provides coverage for an absent practitioner or due to practitioner shortage for a period of 90 consecutive calendar days or less is not required to complete the full credentialing process, but rather an expedited process that will approve credentialing for the Locum Tenens coverage period.
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Hospital Based Enrollment Form - Moda does not credential inpatient setting only practitioners. These are providers who practice exclusively in an inpatient setting and who provide care only as a result of a member's treatment in an inpatient setting. Providers working exclusively in the emergency room of a hospital are considered hospital based, whether providing inpatient or outpatient services.
Provider specialties that fall under this definition per the National Committee for Quality Assurance (NCQA) include: pathology, radiology, anesthesiology, neonatology, emergency medicine and hospitalists.
Please note: Telemedicine providers would not fall under this definition of hospital based, as they are not located within the hospital facility. Full credentialing will be required for this provider type prior to being considered in-network.
Please submit a copy of the Hospital Based Provider Enrollment Form to providerupdates@modahealth.com.
For the enrollment of multiple hospital-based providers, this roster form may be used: Hospital based roster form
Frequently asked questions about credentialing
Is credentialing different than contracting?
Yes. Credentialing and contracting are two separate parts of the practitioner and organizational provider enrollment process. A credentialing approval allows the practitioner or organizational provider to be part of an in-network agreement. Credentialing is required every three years to maintain eligibility. The contracting process is separate and determines the reimbursement rate and in-network status for member plans. Separate lines of business are determined by the contracts negotiated.
What is credentialing?
Prior to allowing network participation, Moda verifies a practitioner's credentials, including but not limited to a valid license to practice, education and training, malpractice history. Information provided within the application will be verified through several entities including the Office of Inspector General, the National Practitioner Data Bank and the appropriate licensing and educational entities.
Do I require credentialing?
What provider type requires credentialing?
Moda requires credentialing for a variety of medical, behavioral health, and alternative care provider types. For a complete list of practitioner types that require credentialing, please see our Moda Practitioner Classification Table. In addition, we also credential organizational providers under the following categories:
- Hospital
- Ambulatory surgery center
- Skilled nursing facility
- Durable medical equipment (DME) supplier
- Home health agency / hospice
- Mental health / chemical dependency / residential treatment facility
- Eating disorder treatment facilities
- Birthing center
- End stage renal disease / renal dialysis
- Federally qualified health center
- Comprehensive outpatient rehabilitation facility
- Rural Health Clinics and Federally Qualified Health Centers
- Clinical Laboratories
Organizational providers are required to be credentialed at each licensed site that is contracted with Moda.
Hospital based only providers
Moda does not credential inpatient setting only practitioners. These are providers who practice exclusively in an inpatient setting and who provide care only as a result of a member's treatment in an inpatient setting. Providers working exclusively in the emergency room of a hospital are considered hospital based, whether providing inpatient or outpatient services.
Provider specialties that fall under this definition per the National Committee for Quality Assurance (NCQA) include: pathology, radiology, anesthesiology, neonatology, emergency medicine and hospitalists.
Please note: Telemedicine providers would not fall under this definition of hospital based, as they are not located within the hospital facility. Full credentialing will be required for this provider type prior to being considered in-network.
Please submit a copy of the Hospital Based Provider Enrollment Form in order to be added to our credentialing and claims systems as hospital based only.
Locum tenens providers
A practitioner who is new to the Moda panel and provides coverage for an absent practitioner, or due to practitioner shortage for a period of 90-consecutive calendar days or less, is not required to complete the full credentialing process. Rather, an expedited process will approve credentialing for the locum tenens coverage period. A practitioner may provide locum tenen coverage for a practice once per calendar year.
Does Moda delegate credentialing to other entities?
Yes. We delegate credentialing to other entities within Oregon, Alaska, and Washington, that meet our standards that are based on the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and the Oregon Division of Medical Assistance Programs (DMAP) criteria. Our current delegates include:
Oregon:
- Oregon Health & Science University
- Central Oregon Independent Practice Association
- PrimeCare
- All Care Independent Practice Association
- Northwest Rehab Alliance (for physical and occupational therapy)
- Tuality Health Plan Services
- Truhearing
- Providence
- Legacy
- Samaritan Health
- Signify IHA
- VSP
- ZoomCare
Alaska:
- Beech Street Alaska (PHCS/MultiPlan)
- FirstChoice Health Network
- Alaska Native Tribe Health Consortium
Washington:
- FirstChoice Health Network (excluding Clark and Cowlitz counties)
- Walla Walla Clinic
If you are already credentialed through one of these entities, you may not require direct credentialing with Moda prior to participation. Please email the Moda Health Credentialing team at credentialing@modahealth.com to confirm.
Credentialing requirements
Learn more about Moda's credentialing process to see the criteria for organizational, individual medical, behavioral health and alternative care providers to participate.
Questions?
We're here to help. Please feel free to contact us with any questions or concerns about our credentialing process.
Provider credentialing documentation may be returned via fax, email or regular mail.
Moda utilizes the CAQH ProView site as an application source. Please send the provider's first name, last name, and CAQH ID to Credentialing@modahealth.com to prompt the use of CAQH to obtain the application.
Important note: CAQH must reflect that Moda has permission to access this application. The application must be up to date with current attestation status to allow the application to be used. Outdated, or incomplete applications will not be accepted or processed.
Toll-free phone number: 855-801-2993
Fax number: 503-265-5707
Email: Credentialing@modahealth.com
Mailing address:
Moda Health
Attn: Credentialing Dept.
601 SW 2nd Ave. #900
Portland, OR 97204
Last updated: Sept 2022
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