Credentialing application process

Before you begin

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

  1. Review our credentialing criteria by provider type to determine if you need to be credentialed. If we require credentialing for your provider type, complete steps 2-3.
  2. You must be registered with the Council for Affordable Healthcare (CAQH) to start the credentialing process. If you aren't registered yet:

    Register with CAQH online

    Or, call them at 888.599.1771 to register.

  3. Contact our Provider Contracting department to make sure we have a contract on file, either for your group or for yourself, prepared and waiting for your credentialing to be confirmed 

Next, complete our automated credentialing process in prism

We use an automated submission process for our credentialing forms.

  1. Complete the online credentialing application at the CAQH website
  2. Log into prism or create a prism account
  3. Select Enrollments & Changes from the main menu, then choose the appropriate option between New Individual Provider Enrollment and New Organizational Provider Enrollment. Follow the prompts* to complete your enrollment request.

    Note: To be eligible for Medicaid participation, you must be actively enrolled in CHAMPS.

  4. We'll send you a confirmation comment in prism with next steps as well as any requests for additional/missing information.

Our processing timeline

When we receive your complete credentialing information, it'll take us up to 90 calendar days to process your request.

 

Check the status of your request

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 any time in prism by clicking on Enrollments & Changes and selecting the Inquiry ID. When you request is completed, you'll receive a comment from our team. Any time our team posts a comment, you'll receive an email notification.

Find your network effective date

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.

If your request has gone over our processing time frames, email us at Exceedsprocessingtime@priorityhealth.com. Be sure to include your Inquiry ID.

Applicant responsibilities

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.

Our review

We review your application and supporting documents for completeness and verify your information. As detailed above, this process takes 90 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
  • Graduation from medical school, verified directly with the medical school or by the American Board of Medical Specialists (ABMS) or American Osteopathic Association (AOA) listings
  • Residency and fellowship (if applicable) verified directly with the training program or by the ABMS or 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, verified by mail, fax and/ or phone
  • 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
  • MDCH - 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 and who aren't employed with or partners of your prospective physician group

Approval & denial

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.