Credentialing application process

You must complete the following steps before our credentialing process can begin:

• Review our credentialing criteria by provider type to determine if you need to be credentialed. If we require credentialing for your provider type, complete the steps below.
• Register with the Council for Affordable Quality Healthcare (CAQH) if you haven’t already:

Register with CAQH online

Or, call them at 888.599.1771 to register.

• Ensure your CAQH application is up to date and re-attested. Also, be sure to authorize Priority Health to view your application. Any CAQH application that doesn't meet these standards will result in delays.
• Maintain active enrollment in CHAMPS to participate in Medicaid.
• Review enrollment support information, if applicable to you, for behavioral health providers, doulas and community health workers (CHWs).

We use an automated, online submission process for our credentialing forms:

1. Log into prism or create a prism account
2. Select Enrollments & Changes from the main menu, then choose the appropriate option:
   Select New Individual Provider Enrollment if you’re enrolling an individual provider or a standard group. A standard group is one that doesn’t need or meet the specific criteria to be screened as an Organization. For example: multi-specialty or behavioral health group without accreditation; primary care group.
   Select New Organizational Provider Enrollment if your facility meets specific criteria to be credentialed and screened as an organization. See the list of Organizations requiring this application type.
   
3. Follow the prompts to complete your request.

You'll see your submitted inquiry listed on your Enrollments & Changes page. We'll communicate with you via prism if we have any requests for additional/missing information. 

When we receive your complete credentialing information, it may take us up to 80 calendar days to process your request.

Note: Each step in this process has a unique timeline that falls within the 80 days. Credentialing is the most time consuming. You may see your inquiry in the credentialing stage for most of the process. This is normal.

Once you submit your request, our team will receive an inquiry. You can check the status of your request and view comments from our team at any time in prism by clicking on Enrollments & Changes and selecting the Inquiry ID.

When your request is completed, you'll receive a comment from our team. Any time our team posts a comment, you'll receive an email notification.

Please avoid submitting a New Comment on your inquiry requesting a status update. This will only delay your processing time. If your request has exceeded 80 calendar days, email us at exceedsprocessingtime@priorityhealth.com. Be sure to include your inquiry ID.

Once your request is complete, you'll receive a final comment from us in prism that includes your network effective date. You can begin billing for dates of service on the network effective date. Claims submitted before the network effective date may result in incorrect payment or denial.

Throughout our credentialing and enrollment process, you're responsible for:

1. Responding to requests for information made by our credentialing staff, the Credentialing Committee, Quality Integration Committee or Board of Directors; and
2. Keeping us informed of any changes in your status relative to the criteria.

For example, you should notify the Committee regarding any:

• Judgment, settlement, or compromise in a professional liability action;
• Action limiting or suspending your license to practice a profession, or your authority to prescribe medication;
• Exclusion from the Medicare or Medicaid programs;
• Cancellation of professional liability coverage; or
• Loss or significant curtailment of clinical privileges at a licensed hospital.

We review your application and supporting documents for completeness and verify your information. As detailed above, this process can take up to 80 calendar days.

Your application is complete when we've received, verified and/or completed the following:

• Completed application and signed attestation and release, including copies of professional liability insurance (minimum limits of $100,000/ $300,000)
• Professional liability claims history, verified directly with the National Practitioner Data Bank
• Applicable state and controlled substance licenses, verified through the state departments of licensing
• Federal DEA license verified, registered in Michigan
• Graduation from medical school, verified directly with the medical school or via state licensure
• Residency and fellowship (if applicable) verified directly with the training program or via the American Board of Medical Specialists (ABMS) or American Osteopathic Association (AOA) listings
• Board certification, verified with the ABMS, AOA, American Board of Podiatric Surgery, American Board of Podiatric Orthopedics and Primary Podiatric Medicine, American Board of Oral Surgery, American Board of Sleep Medicine, or American Board of Addiction Medicine listings (see individual criteria for exceptions)
• Current and previous hospital memberships
• CHAMPS enrollment verified, Medicaid only
• Medicare Opt-out Report
• National Practitioner Data Bank (NPDB), queried online to verify any disciplinary actions, malpractice payments and Medicare/ Medicaid sanctions
• MDHHS Medical Services Administration Sanctioned Providers
• Office of Inspector General Sanctioned Provider Exclusion Database
• System for Award Management (SAM)
• Letters of recommendation, if requested, from physicians who are familiar with your clinical skills

The Credentialing Committee approves or denies your application.

You have the right to review certain information submitted in support of your application and to amend erroneous information submitted by another party. These rights are fully described in the Priority Health Practitioner Rights Policy.

Avoid these common causes of credentialing application processing delays:

• No W9 attached for new groups
• No signed contract attached for new Behavioral Health groups
• No professional AND general liability insurance attached for organizations
• Submission of incorrect application type (individual vs organization)
• Missing primary hospital affiliation
• Non-response to requests for additional information

Additional tips to avoid incorrect submissions:

• Select Advanced Practice Professional as the Practice type for all Nurse Practitioner, Physician Assistant and Certified Nurse Midwife applications.
• The Provider Specialty for Advanced Practice Professionals should be a practice specialty (rather than Physician Assistant or Nurse Practitioner).
• Applicable ACN / PO / PHO information should be included on applications, and delegate requests must be submitted through the delegation.
• The Primary Address in your application should be the practice location. PO Boxes aren’t appropriate as practice locations.

Q: How do I add a provider to an existing, credentialed group?

A: Situation: You have a provider to add to a standard group that’s already participating with us.

Action: Submit an individual provider enrollment request for the provider.

Our process: Once we have a group set up in our system, any subsequent individual provider enrollment requests received with the same group information will be added to the group in our system.

Q: How do I set up a new standard group?

A: Situation: You have a new group to enroll with Priority Health, one that doesn’t meet the requirements to be an Organizational provider.

Action: Submit an individual provider enrollment request for each provider in the group.

Our process: When we receive an enrollment application, we first verify whether the group the provider is associated with is already participating with us or not. If we find the group to be new to Priority Health / not currently participating in our network, we’ll both enroll the provider and set up a new group in our system.

Q: How do I submit provider changes?

A: Follow these instructions to notify us of changes in your name, address, staff, tax ID number or if you're opening or closing to new patients. You must notify us 60 days ahead of the change.