Credentialing

Credentialing Applications

Practitioners

Medical Mutual participates in the one-stop credentialing application process using CAQH ProView, developed by the Council for Affordable Quality Healthcare (CAQH). ProView enables practitioners to submit their information in a secure, free of charge, centralized database to satisfy most credentialing and recredentialing requirements of participating plans.

CAQH participation is voluntary and encouraged for all SuperMed network practitioners, unless otherwise mandated by state regulation. Please see http://proview.caqh.org/PR for more information about CAQH. 

Organizations

Organizations such as Ambulatory Surgery Centers, Home Health Agencies, Skilled Nursing Facilities etc. applying for network participation must use a facility credentialing form. Ohio organizations are required to use the state-mandated credentialing form developed by the Ohio Department of Insurance.

View Ohio Department of Insurance Form

Organizations in other states must use the Medical Mutual Standardized Credentialing Form.

View Medical Mutual Standardized Credentialing Form

Click on any link above for additional information or to view a credentialing form. If you have any additional questions, please contact your local Medical Mutual Provider Contracting Office at 1-800-625-2583.

Credentialing Requirements

Minimum credentialing requirements for practitioners utilizing the Health Care Financing Administration (HCFA) Form to submit claims include, but are not limited to, the following:

• Completed credentialing application with current attestation and release
• Valid Professional License
• Valid DEA Certificate (where applicable)
• Proof of current malpractice coverage
  • The provider shall maintain adequate professional liability or malpractice insurance in an amount required by the applicable state law or at least $1,000,000 per occurrence/$1,000,000 annual aggregate, whichever is lower.
• Appropriate Professional Training
  • Graduation from appropriate professional school
  • Residency/Fellowship
  • Board Certification
  • Appropriate professional experience
  • Provider’s specialty designation in the Company directory is at the discretion of the Credentialing Committee
• Appropriate clinical privileges at a Network Hospital (where applicable)
• Work History
• Malpractice History
• Office Site and Medical Record Review (where applicable)

Provider Credentialing Rights

Practitioners have the right to be informed of the status of their credentialing or re-credentialing application upon request.

Upon receipt of a written request, the Company will provide practitioners with the status of their credentialing or re-credentialing application within 15 business days. The information provided will advise of any items still needing to be verified, any non-response in obtaining verifications and any discrepancies in verification information received compared to information provided by them. Written requests shall be directed to:

Medical Mutual of Ohio
100 American Rd
Cleveland, Ohio 44144
Attn: Manager, Provider Network Services; 01-6A-3983

Practitioners have the right to review information submitted in support of their credentialing or re-credentialing application.

Practitioners may review any documentation submitted by them in support of their credentialing or re-credentialing application, together with any discrepant information relating, but not limited to, education or training; liability claims history; state licensing; certification boards; professional societies, etc. Peer review information obtained by the Company may not be reviewed.

Practitioners have the right to correct erroneous information and receive notification of the process and timeframe.

In the event the credentials verification processes reveal information submitted by a practitioner that differs from the verification information obtained by the Company, the practitioner is allowed to submit corrections for the erroneous information.

The Company's notification communication will include:

• The nature of the discrepant information;
• The format for submitting corrections;
• The time frame for submitting the corrections;
• The addressee to whom corrections must be sent.

The Company's notification process will include:

• A request indicating the name and address of the person to whom a response should be sent;
• A copy of the application page(s) with the discrepant information identified;
• A request to make the necessary corrections on the page(s) provided, to initial and date the corrected information and return the documentation to the Company together with a written explanation within 10 calendar days of receipt of the request;
• A request that the correction information be faxed or mailed to the credentialing specialist named on the request at the address also provided on the request;
• Upon receipt of the corrected information by the Company, the completed credentialing application, which includes the appropriate verifications and the corrected information provided by the practitioner, is then submitted through the Company’s credentialing approval process;
• Notification of the credentialing decision is provided to the practitioner in writing.