Uniform Credentialing Process
The Massachusetts Physician Credentialing Initiative establishes a standardized process for physician credentialing by health plans and hospitals. This effort streamlines and simplifies the credentialing process, featuring a uniform application for physicians
to complete, copy and submit to each health plan and hospital with which they seek affiliation. Participating health plans will process 95% of complete initial applications within 30 days, and communicate regularly with physicians on application status. Physicians
who have been credentialed through this process will be allowed to treat plan enrollees and be reimbursed by the applicable health insurance plan for covered services effective as of the plans' credentialing date.
Industry Collaboration
This initiative is sponsored by the Massachusetts Association of Health Plans, Blue Cross Blue Shield of Massachusetts, the Massachusetts Hospital Association and the Massachusetts Medical Society, while initial participants include Harvard Pilgrim Health
Care, Fallon Community Health Plan, Health New England, Tufts Health Plan, Neighborhood Health Plan, Network Health, Connecticare, Harvard Vanguard Medical Associates, Massachusetts General Hospital, Massachusetts General Physician's Organization,
NEMSO-Beverly Hospital, Brigham & Women's Hospital, and Brigham & Women's Physician Organization, Northeast PHO, Heywood Hospital, Melrose Wakefield IPA, Inc., Emerson PHO IPA, Emerson Hospital, Hallmark Health System, North Shore Health System, North
Shore Medical Center, Shaughnessy-Kaplan Rehabilitation Hospital, Lawrence Memorial IPA, Harrington PHO and Mary Lane Hospital. For any questions, please contact your health plan.
In addition, the uniform credentialing applications will be accepted by Aetna, CIGNA, Private Healthcare Systems and UnitedHealthcare. For any questions, please contact your health plan.
Process Highlights
- Uniform initial credentialing application (excluding psychiatrists) at participating health plans and hospitals
- Uniform recredentialing application, along with plan/hospital-specific profile forms to be used by all physicians (excluding psychiatrists), at participating health plans and hospitals
- Standard criteria for hospital-based physicians
- Standard reporting of application status
- Turnaround time for 95% completed initial applications within 30 days
Meeting the 30-day turnaround standard for initial applications will require that providers submit complete applications; incomplete applications will be returned with a cover letter identifying the missing or incomplete information. A complete application
shall include:
- An application that is signed and appropriately dated by the physician applicant
- Complete and legible information
- Explanations that are satisfactory to the health plan, to any affirmative answer
- A current CV with appropriate required dates in months and years
- A signed, currently dated Applicant's Authorization to Release Information form
- Copies of current licenses in all states in which the physician practices
- Copies of current Massachusetts controlled substances registration and federal DEA controlled substance certificate, or if not available, a letter describing prescribing arrangements
- Hospital letter or verification of hospital credentialing (or alternative pathways)
- A copy of current malpractice face sheet coverage statement indicating name of insurer, amounts and dates of coverage
- Documentation of Board certification (or alternative pathways)
- Documentation of training (if not Board-certified)
- No affirmative responses on questions related to quality or clinical competence
- No modifications to Applicant's Authorization to Release Information form
- No discrepancies between physician-provided information and information received from other sources
- Appropriate Health Plan participation agreement(s), if applicable
- W-9
Massachusetts Uniform Credentialing Applications
Other Resources
