Credentialing

The Credentialing team at Martin’s Point Health Care (or its designated qualified agent) reviews provider and/or facility applications and documentation in order to determine participation in our health plan networks. Martin’s Point uses a standardized process to ensure that it treats all applicants in a fair and nondiscriminatory manner. The health plan medical director is directly responsible for oversight of the Martin’s Point credentialing program, and is chair of the Credentials Committee. The Credentials Committee is a peer review group that has the final authority in deciding the initial and continuing participation of practitioners and facilities.

Martin's Point credentials the following provider types: 

  • MD, DO, DDS, DPM, OD, DC, AuDand Certified Nurse Midwives (CNM)
  • Nurse Practitioners (FNP, ANP, PNP) and Physician Assistants (PA) who practice as a PCP

Martin's Point does not credential:

  • PT, OT, ST, SLP practitioners (Martin’s Point credentials the group)
  • Providers who practice exclusively within the inpatient setting (e.g., hospitalist, laboratory personnel)
  • Nurse Practitioners and Physician Assistants who practice as specialists
  • Covering Physicians (e.g., locum tenens, per diems)
  • Martin’s Point does not contract with Chiropractors (DC) for the US Family Health Plan.

Applicants must meet the following criteria to participate in a Martin’s Point network:

A. Current unrestricted license for all states in which an applicant will treat a Martin’s Point health plan member or patient

B. Current unrestricted federal Drug Enforcement Agency (DEA) or Controlled Dangerous Substance (CDS) certificate, as applicable to an applicant’s scope of practice

C. Current professional liability insurance coverage, including the current coverage period and a minimum coverage of $1M/$3M

D. Completion of appropriate education and professional training for an applicant’s scope of practice and licensure. If an applicant is not board certified, the highest level of education or training attained is verified.

E. No unexplained work history gaps of six months or longer for the five years preceding initial credentialing. (Note: Work history refers to relevant work that is applicable to the position. If an applicant is a new health care professional, work history begins at the time when the provider has completed his or her professional training.)

F. Board certification in contracted specialty or board-eligibility status, if applicable to the practitioner type. Board-eligible applicants must indicate the month and year he or she expects to achieve this credential. Martin’s Point expects an applicant to achieve this credential within six years of the provider’s initial credentialing approval date. (See Board Certification section.)

G. Absence of sanctions and felony convictions. (Note: The Credentials Committee may approve the participation of an applicant with sanction history if, in the professional judgment of the Credentials Committee, the applicant has redeemed himself or herself and the sanction would not impact the ability of the applicant to provide quality care to Martin’s Point health plan members.)

H. Absence of loss or limitation of privileges or disciplinary activity. (Note: The Credentials Committee may approve the participation of an applicant with privilege limitation or disciplinary history if, in the professional judgment of the Credentials Committee, the applicant has redeemed himself or herself and the sanction would not impact the ability of the applicant to provide quality care to Martin’s Point health plan members.)

I. An acceptable professional liability claims history, including, but not limited to, claims that resulted in settlements or judgments paid by or on behalf of an applicant. (Note: The Credentials Committee reviews all files that contain a paid claim with an occurrence date within the past 10 years. The committee’s professional judgment determines what constitutes an acceptable claims history.)

J. Hospital affiliations or privileges (when applicable to practitioner type and scope of practice) in at least one contracted network hospital, or appropriate admitting arrangements.

K. No physical, mental, or substance abuse problems, or any limitations in ability to perform the functions of the position, that could, without reasonable accommodation, impede an applicant’s ability to provide care according to accepted standards of professional performance or pose a threat to the health or safety of patients.

L. A signed and dated statement attesting that the information submitted with the application is complete and accurate to the applicant’s knowledge.

M. A signed and dated statement authorizing Martin’s Point to collect any information necessary to verify the credentialing application.

N. Must not charge a ‘membership fee’ or ‘service fee’ to our members for services that are, in whole or in part, a covered Medicare/TRICARE service.  Imposition of such charges is in direct conflict with CMS and TRICARE guidance and will result in termination or lack of entry into the network.

Reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0421.pdf

The burden is on an applicant to provide any documentation that may be requested by Martin’s Point (or its designated qualified agent) in order to complete his/her file, and determine whether the applicant meets the participation and credentialing criteria. Applicants will receive notification of the medical director’s or Credentials Committee’s decision regarding their application within 60 calendar days of the decision. A Martin’s Point credentialing approval must be received prior to treating our members.

Martin’s Point credentials all practitioners without regard to race, color, sex, ethnic/national origin, religion, age, sexual orientation, types of procedures or patients in which the practitioner specializes, or mental or physical disability unless the mental or physical disability may affect the practitioner’s ability to render care safely and competently.

Board Certification

Martin's Point requires that all providers be board certified, or board eligible in their contracted specialties. This requirement excludes optometrists, chiropractors and audiologists. MPHC will review a provider’s board certification information during his/her initial credentialing, and at the time of recredentialing (every three years). If a provider states that s/he is board-certified in his/her contracted specialty, verification will be completed through an NCQAapproved primary source. Martin’s Point recognizes the following specialty boards:

Physicians: Boards approved by the American Board of Medical Specialties (ABMS), American Osteopathic Association (AOA), the College of Family Physicians of Canada (CFPC), the Royal College of Physicians and Surgeons of Canada (RCPSC), Royal College of Surgeons of England (RCS), Royal College of Surgeons of Edinburgh (RCSEd), Membership of the Royal Colleges of Physicians of the United Kingdom (MRCP(UK)), including Royal College of Physicians of London (RCP), Royal College of Physicians of Edinburgh (RCPE), and Royal College of Physicians and Surgeons of Glasgow (RCPSG)

Nurse Practitioners: American Academy of Nurse Practitioners (AANP), American Nurses Credentialing Center (ANCC), or Pediatric Certification Nursing Board (PCNB)

Physician Assistants: National Commission on Certification of Physician Assistants (NCCPA)

Certified Nurse Midwives: American Midwifery Certification Board (AMCB)

Podiatrists: American Board of Foot and Ankle Surgery (ABFAS) and the American Board of Podiatric Medicine (ABPM)

Oral Surgeons: American Board of Oral and Maxillofacial Surgeons (ABOMS)

Board Exemptions

Martin’s Point recognizes that there may be instances in which a provider is neither board certified in his/her contracted specialty, nor planning to pursue certification. The provider may be credentialed if s/he meets the criteria of one of the following exemptions:

 • Pre-1996 Exemption: Initial applicants and providers applying for recredentialing who have successfully completed a graduate medical education program on or before January 1, 1996, may be considered exempt from having to be board certified in their contracted specialty.
- This exemption applies to MD, DO and DPM providers only.
- The training program must be a Residency or Fellowship, accredited through the ACGME, the AOA, or the Canadian or UK equivalent. The program must be within the scope of the provider’s contracted specialty.
- The Credentials Committee reserves the right to deny or terminate a provider’s network participation even if he/she has met criteria outlined above.

 • Essential Role Exemption: In some instances, applicants who are not board eligible, and have not completed their residency program on/after January 1, 1996, may still request participation with the Martin’s Point provider network. To be considered for exemption status, an applicant must perform or provide an essential role in the community.
- The Credentials Committee will consider providers applying for this exemption on an individual basis.
- This exemption applies to MDs, DOs, DDSs, DPMs, and CNMs. NPs and PAs who are being credentialed as a PCP may also apply for this exemption.
- All of the following conditions must be met before the Credentials Committee reviews the provider’s credentialing application:
a) The Network Management Department must confirm that there is an ongoing geographic and specialty need within the existing MPHC network(s).
b) The applicant must have successfully completed a graduate medical education program in his/her contracted specialty.
• MDs, DOs, and DPMs must have must have completed a program that is accredited through the ACGME, the AOA or the Canadian or UK equivalent.
• Non-physician practitioners must have completed a master’s or post-master’s level program in his or her practicing specialty.
c) The applicant must complete continuing medical education (CME) every two years with an accumulation of 50 hours:
• AMA Category One Credits
• AOA equivalent
• Non-physician practitioners must have equivalent continuing education criteria pre-approved by the Credentials Committee
- The applicant must provide the following documentation in support of a request for an exemption:
a) A letter requesting an exemption from the board certification requirement. This letter should provide an explanation of the essential role that the provider plays in his/her community, as well as an account of his/her specialty training.
b) A letter attesting to his/her ongoing maintenance and completion of the required continuing education credits.
c) Three letters of reference from his/her peers. The letters must be current (within one year), and must be written on the letterhead of the practitioner or facility. The provider may submit one letter with three provider signatures in lieu of gathering three separate letters.
- If the applicant does not submit all the information and supporting documents as required, MPHC will consider the credentialing application incomplete. The application will be discontinued, and the provider will be eligible to reapply once s/he is able to provide the necessary information.

Ongoing Monitoring, Terminations and Appeals

It is the policy of MPHC to monitor its practitioners for continued compliance with criteria for active participation within its health plan networks. This includes the ongoing monitoring of license sanctions and limitations on scope of practice.

MPHC‘s Health Plan Medical Director (or designated physician) may impose a range of actions (defined under ‘Monitoring of State Sanctions or Limitations on Licensure’) for practitioners whose scope of practice has been limited by the state licensing board, or who, in his/her professional opinion, may pose a significant risk of harm to members. If appropriate, this process includes a provision of the practitioner’s appeal rights, as well as notification to authorities. Providers who have been sanctioned by the state licensing board, and/or are determined to not have a current active license, may be immediately terminated without the right to an appeal. For those practitioners who are terminated due to quality related concerns, MPHC will provide a right to an appeal hearing, and notification to the applicable authorities.

Monitoring of State Sanctions or Limitations on Licensure

The following guidelines are followed when reviewing notifications and making appropriate decisions regarding a practitioner’s participation, and appeal rights will apply:

License Action Martin's Point Health Care Action
Non-disciplinary action may include:
  • Letters of guidance
  • Letters of concern
  • Official reprimand
  • Monetary fines 
  • No immediate action taken between 36-month credentialing cycles
  • Non-disciplinary action will be reviewed with a practitioner's inial credentialing application and upon re-credentialing.
Actions not limiting scope of practice may include:
  • Continuing medical education
  • Therapy, substance abuse treatment
  • Probation
  • No immediate action taken between 36-month credentialing cycles
  • Defer to state's decision(s) on monitoring action(s)

Restricted license:

  • Restriction on aspect of license or certification(s) that require another practitioner to oversee one's work (i.e., supervision and/or monitoring)
  • Health plan medical director (or designated physician) reviews
  • Practitioner may immediately be imposed a range of actions, including termination from the network
  • Provider is allowed the right to an appeal, if terminated

Suspended or inactive license:

  • License not currently active
  • If participating, Martin's Point immediately terminates the practitioner from the network*
  • If provider has applied for initial credentialing, his/her application will be discontinued.

Sanctioned or excluded practitioners:

  • Monitored by Compliance and Program Integrity, as detailed in the CC018-01 Excluded, Sanctioned and Opted-out Lists policy.
  • DHHS/OIG definitions of mandatory or permissive exclusions apply. For more information, please visit: http://exclusions.oig.hhs.gov
  • If participating, Martin's Point immediately terminates the practitioner from the network.
  • If provider has applied for initial credentialing, his/her application will be discontinued.

*If a practitioner is terminated due to suspension, he or she may request to reenter the network without going through the initial credentialing process if his or her license is reinstated within 30 calendar days of the suspension. The provider (or his/her designee) must submit this request in writing within thirty (30) business days of date that the license was reinstated.

Additional information regarding the decision-making procedure can be provided upon request.

Termination and Appeals Procedure

The termination and appeals procedure will apply:

• If the Health Plan Medical Director (or designated physician) concludes that the practitioner’s licensure action is a result of serious quality events or adverse behavior and may pose a significant risk of harm to members
• To practitioners who are terminated for quality reasons during recredentialing or mid-cycle Credentials Committee follow-up

If termination of the practitioner’s network participation is determined, the following steps are taken:

1. The Health Plan Medical Director (or designated physician) notifies the Credentialing staff of the determination to terminate the provider. This notification will be forwarded via email to the Network Specialist Team as well as to the appropriate Network Representative.
2. The Credentialing staff will draft a termination letter that will be signed by the Health Plan Medical Director, and mailed directly to the practitioner via certified letter. The letter will include:
a. The action being taken.
b. The reason for the action.
c. Notification of his/her right to an appeal hearing.
d. Notification that s/he is allowed up to thirty (30) calendar days after the notification to request the hearing.
e. Notification that s/he may be represented by an attorney, or another person of their choice, during the appeal.
f. Notification that MPHC will appoint a panel to review the appeal. This panel will consist of three qualified individuals, at least one of whom is a clinical peer (like specialty) and not part of the network management.
g. Notification that s/he has the right to furnish the panel with additional information/documentation or testimony for consideration.
3. The practitioner has thirty (30) calendar days to respond in writing to the Health Plan Medical Director, to request an appeals hearing.
4. If the practitioner requests an appeal:
a. The hearing will convene on a mutually agreed-upon time after the receipt of the request.
b. The appeal panel will consist of three qualified individuals, at least one of whom is a clinical peer (like specialty) and not part of the network management.
c. Participants of the appeal hearing may appear in person or via teleconference.
d. Legal counsel or another person of the practitioner’s choice may represent him or her.
e. The practitioner may furnish the committee with documentary and verbal information at the hearing.
f. All actions of the appeal process are protected under peer review statutes.
g. The termination will remain in effect during the appeal period.
5. The Health Plan Medical Director informs the practitioner of the decision and the reasons for the decision in writing within ten (10) business days from the date of the appeal decision.
6. If the panel’s determination is not in favor of the practitioner, his/her termination will remain in place.

Additional information about the appeals process can be provided upon request

Reporting to Authorities

If MPHC terminates a practitioner for quality reasons, it will notify the applicable authorities, including state licensing agencies and the National Practitioner Data Bank (NPDB). Notification will be sent thirty (30) calendar days after the termination notice, allowing the practitioner time to request an appeal hearing. If the practitioner requests in an appeal, notification will be sent within ten (10) business days after the appeal decision has been completed, and if the Health Plan Medical Director’s decision to terminate is upheld. Notification applies to both physicians and non-physicians.

Starting the Credentialing Process

To initiate the MPHC credentialing process:

• Complete the Council for Affordable Quality Healthcare (CAQH) application at https://proview.caqh.org
• Ensure all information and attached documents have been updated and (re)attested.
• MPHC must be authorized to view your CAQH information.
• Your contracted practice location must be reflected on your CAQH application.
• Your board certification information must be reflected on your CAQH application.
• Using the CAQH Universal Credentialing DataSource does not grant participation, or constitute an application for participation, in the MPHC provider network.
• Once your CAQH application is complete, please provide Martin's Point with your provider data via Credentialing
For questions, contact [email protected] or call 1-207-828-7870.

Our Credentials Verification Organization (CVO)
Effective January 2, 2013, MPHC has entered into a relationship with a Credentials Verification Organization (CVO) called Aperture Credentialing Inc. Aperture offers primary source verification services as part of the MPHC credentialing of providers participating in the US Family Health Plan and Generations Advantage networks. Providers may receive correspondence related to MPHC credentialing from our CVO partner. Aperture may request that provider offices complete a CAQH application and/or provide additional documents or information. Any requests that provider offices may receive from Aperture are legitimate and essential to provider participation in the Martin's Point's network.

Practitioner Rights

All practitioners have the following rights during the credentialing process. Requests can be made via telephone, e-mail or mail: 
During the credentialing or recredentialing process, applicants have the right to review information submitted to support their applications, to correct erroneous information and to receive the status of their credentialing/recredentialing applications upon request. MPHC notifies applicants of these rights via the Credentialing Provider Data Form and online provider manual. Applicants can make these requests via telephone, e-mail or mail. An applicant can also request an appointment to review his or her file. Before the agreed-upon appointment time, the Credentialing Specialist (or designee) removes any information from the file that is protected and not subject to disclosure. The Credentialing Specialist (or designee) is present while the applicant reviews the file.

If there is a discrepancy between information received in an application and information found during primary source verification, the Credentialing Specialist notifies the applicant in writing, and requests a written correction of the discrepancy within ten (10) business days. Replies should be sent via e-mail to the Credentialing Specialist initiating the request, or by mail to the following address:

Attention: Credentialing
Martin’s Point Health Care
PO Box 9746
Portland, ME 04104-5040
1-800-348-9804

Facilities

MPHC requires that each facility complete an appropriate application and provide supporting documents / information if applicable. MPHC credentials the following facilities:

• Hospitals (Acute Inpatient Facilities)
• Ambulatory Surgery Centers
• Home Health Agencies
• Skilled Nursing Facilities
• Hospice Groups
• End-Stage Renal Service Providers
• Rural Health Clinics
• Federally Qualified Health Centers
• Physical Therapy Groups
• Occupational Therapy Groups
• Speech Therapy & Speech Language Pathology Groups

Facility applicants must meet the following criteria to participate in an MPHC network:

A. Current facility state license without restrictions (Individual practitioner licensing is acceptable for PT, OT, ST & SLP groups)
B. Current Medicare certification without restrictions
C. Current professional liability insurance coverage, including the current coverage period and a minimum coverage of $1M/$3M. (Individual practitioner coverage is acceptable for PT, OT, ST & SLP groups)
D. MPHC requires a facility to be free of conditions imposed by the Department of Health and Human Services (DHHS), and free of restrictions or sanctions imposed by the Office of Inspector General (OIG).
E. MPHC requires selected facility types to provide its current accreditation status with acceptable accrediting bodies as follows:
- JC (Joint Commission)
- HFAP (Healthcare Facilities Accreditation Program)
- DNV (Det Norske Veritas Healthcare)
- ACHC (Accreditation Commission for Healthcare)
- CHAP (Community Health Accreditation Program)
- CARF (Commission on Accreditation of Rehabilitation Facilities)
- AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities)
- AAAHC (Accreditation Association for Ambulatory HealthCare)

If a facility is not accredited, it must have had a CMS/state survey performed within the past three years. If a facility is not accredited and cannot provide a current CMS/State survey, MPHC performs an on-site quality assessment. (Accreditation or CMS/State Survey is not required for PT, OT, ST & SLP groups.)

If you have any questions about the MPHC credentialing process, you may contact us at:

Email: [email protected]
Phone: 1-800-348-9804

The credentialing process is generally required by Law. The fact that a provider is credentialed is not intended as a guarantee or promise of any particular level of care or service.