Credentialing
Medical Mutual credentials all providers applying to participate in our networks and periodically thereafter for the duration of the providers’ participation in those networks. Providers may only participate in Medical Mutual’s networks after being reviewed by Medical Mutual through the credentialing and recredentialing process and if they receive approval from Medical Mutual to participate in our networks.
Practitioners
Medical Mutual participates in the one-stop credentialing application process using CAQH ProView, developed by the Council for Affordable Quality Healthcare (CAQH). 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. Please see http://proview.caqh.org/PR for more information about CAQH.
Ohio law requires that Medical Mutual use the CAQH credentialing application to perform credentialing and recredentialing of practitioners practicing in the State of Ohio.
If the practitioner group’s Tax Identification Number (TIN) is currently contracted with Medical Mutual and the group would like to request credentialing for a practitioner in the group, please submit a completed Provider Information Form (PIF).
If the practitioner group’s TIN is not currently contracted with Medical Mutual and the group would like to request eligibility information to become a network provider, please contact Medical Mutual’s provider contracting department utilizing the Network Provider Enrollment Form.
Please Note: Credentialing can take up to 90 days to complete once a request has been submitted, the CAQH application has been re-attested to, and Medical Mutual has been authorized to obtain the application.
Facilities
Organizations such as, but not limited to, ambulatory surgery centers, home health agencies, skilled nursing facilities, and freestanding behavioral health facilities applying for network participation must use a facility credentialing form. Ohio organizations are required to use the State of Ohio-mandated credentialing form, which was developed by the Ohio Department of Insurance.
If you have any questions, please contact your local Medical Mutual Provider Contracting Office at 1-800-625-2583.
Practitioners
Minimum credentialing requirements for practitioners utilizing the CMS-1500 Form to submit claims include, but are not limited to, the following:
- Signed network contract with Medical Mutual
- Completed credentialing application with current attestation and release
- Unrestricted Professional License
- Valid DEA Certificate (where applicable)
- Proof of current malpractice coverage
- The practitioner shall maintain adequate professional liability or malpractice insurance in an amount required by 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
- Note: Practitioner’s specialty designation in the Medical Mutual directory is at the discretion of the Credentialing Committee
- Appropriate clinical privileges at a network hospital (where applicable)
- Review of work history
- Review of malpractice history through the NPDB
- Standard Care Agreement/Supervisory Agreement for Nurse Practitioners and Physician Assistants (where applicable)
- A copy of the Standard Care Agreement/Supervisory Agreement or a completed copy of the affiliation forms can be sent to providerpifs@medmutual.com.
- Absence of Medicare and Medicaid Sanctions
Facilities
Minimum credentialing requirements for facilities utilizing a UB-04 Form to submit claims include, but are not limited to, the following:
- Signed network contract with Medical Mutual
- Completed credentialing application with current attestation
- Valid Facility/Professional License
- Valid DEA Certificate (where applicable)
- Absence of Medicare and Medicaid Sanctions
- For hospitals and behavioral health facilities- Appropriate accreditation
- For other facilities besides hospitals and behavioral health facilities- Appropriate accreditation, copy of CMS site survey (within the past 3 years), or a successful Medical Mutual Onsite Quality Assessment.
Please see the Accepted Accreditations document for the required accreditation documentation for facility type. If the facility provides multiple services, the credentialing criteria must be individually met for each specialty listed.
Practitioners
Medical Mutual requires recredentialing every three years. The recredentialing process is automatically initiated with an updated CAQH application for practitioners. If the CAQH application is not current at the time the practitioner is due for recredentialing, Medical Mutual will notify the practitioner at the last known credentialing address to request that the practitioner review and update the CAQH application to initialize the recredentialing process.
If Medical Mutual does not obtain an updated application to initiate the recredentialing process, or if the practitioner does not submit required data to meet the credentialing criteria, the practitioner may be subject to termination from Medical Mutual’s networks due to nonparticipation in the recredentialing process.
If the practitioner receives an intent to terminate letter and would like to appeal the termination, or if the practitioner receives a final termination letter and has questions regarding the termination or how to re-apply for network participation, please email admincredentialing@medmutual.com.
Facilities
Medical Mutual requires recredentialing every three years. The recredentialing process is automatically initiated by Medical Mutual utilizing the facility’s last credentialed date. Facility licensure, DEA (if applicable), and applicable appropriate accreditation and/or CMS site survey will be primary source verified through state and/or federal agencies. If the facility is not accredited or has not had a CMS site survey completed within the past 3 years, the facility is subject to Medical Mutual’s Onsite Quality Assessment. The facility will be contacted if there is information needed to finalize the recredentialing process.
If the facility receives an intent to terminate letter and would like to appeal the termination, or if the facility receives a final termination letter and has questions regarding the termination or how to re-apply for network participation, please email admincredentialing@medmutual.com.
Providers have the right to be informed of the status of their credentialing or re-credentialing application upon request.
Upon receipt of a written request, Medical Mutual will provide the provider with the status of the credentialing or recredentialing application within 10 business days. The information provided will advise of any items still needing verification, any non-response in obtaining verifications, and any discrepancies in verification information received compared to information provided by the provider. Written requests must be directed by email to providerpifs@medmutual.com, or by mail to the address listed below, and should include the provider’s NPI and Tax Identification Number.
Medical Mutual
100 American Rd
MZ 02-3B-3983
Brooklyn, Ohio 44144
Attn: Manager, Provider Credentialing & Data Management
Providers have the right to review information submitted in support of the credentialing or recredentialing application.
Providers may review any documentation submitted by the Provider in support of the credentialing or recredentialing application, together with any discrepant information relating to information such as, but not limited to, education or training; liability claims history; state licensing; certification boards; and professional societies. Peer review information obtained by Medical Mutual may not be reviewed.
Providers have the right to correct erroneous information and receive notification of the process and timeframe.
In the event the credentials verification process reveals information submitted by the provider that differs from the verification information obtained by Medical Mutual, providers are allowed to submit corrections for the erroneous information.
Medical Mutual's notification communication will include:
- The nature of the discrepant information
- The format for submitting corrections
- The timeframe for submitting corrections
- The address where corrections must be sent
Medical Mutual's notification process will include:
- A request indicating the name and address of the person to whom a response should be sent
- A request to make the necessary corrections on the identified pages, reattest on CAQH ProView with the corrected information, and advise Medical Mutual that the information was corrected within 10 calendar days of receipt of the request
- A request that the corrected information be faxed or emailed to the credentialing specialist named on the request at the address provided on the request
- Upon Medical Mutual’s receipt of the corrected information, the completed credentialing application, which includes the appropriate verifications and the corrected information the provider provides, is then submitted through Medical Mutual’s credentialing process
- Notification of the credentialing decision is provided to the provider in writing
Additional Information
Updates to Provider Demographics
Any updates to provider demographics (which include, but are not limited to, the addition of office locations, the removal of office locations, and changes to already existing information) must be submitted to Medical Mutual utilizing the Provider Information Form.
Provider Directory Accuracy
Medical Mutual has engaged Quest Analytics BetterDoctor to help verify the accuracy of the provider information listed in our provider directory on a quarterly basis. A fax with an access code to the BetterDoctor portal giving access to review the provider’s data is sent to each provider group each quarter. When provider groups receive the fax, they should log in to the BetterDoctor portal and verify the accuracy of the information that Medical Mutual has listed for them in our provider directory.
Provider Portal
Medical Mutual uses Availity as our Provider Portal. Providers can use the portal to access:
- Eligibility and Benefits
- Claims Status
- Electronic Remittance Advice (eRA) Statements
- Fee Schedule Lookup
- Provider Record Updates
- Provider Action Request (appeal form)
Providers can also view news and announcements and sign up for email communications within the portal. If you are not registered for Availity, you can do so here.