Contracting & Credentialing

All of the following providers are required to be credentialed:

• Medical practitioners
• Medical doctors
• Oral surgeons
• Chiropractors
• Osteopaths
• Podiatrists
• Nurse practitioners
• Practitioners who are licensed, certified or registered by the state to practice independently (without direction or supervision)
• Practitioners who have an independent relationship with the organization
• Practitioners who provide care to members under the organization’s medical benefits
• Other medical practitioners

Behavioral healthcare practitioners

• Psychiatrists and other physicians
• Addiction medicine specialists
• Doctoral or master's-level psychologists
• Master's-level clinical social workers
• Master's-level clinical nurse specialists or psychiatric nurse practitioners
• Other licensed behavioral healthcare specialists

All new practitioners and those adding practitioners to their current practice must submit at a minimum the following information when applying for participation with Iowa Total Care:

• A completed, signed and dated Credentialing application
• Providers can authorize Iowa Total Care access to their information on file with the Council for Affordable Quality Health Care (CAQH)
• A signed attestation of the correctness and completeness of the application, history of loss of license and/or clinical privileges, disciplinary actions, and/or felony convictions; lack of current illegal substance registration and/or alcohol abuse; mental and physical competence, and ability to perform the essential functions of the position, with or without accommodation (attestation must be no more than 120 days at time of submission for enrollment)
• Copy of current malpractice insurance policy face sheet that includes expiration dates, amounts of coverage and provider's name, or evidence of compliance with Iowa regulations regarding malpractice coverage or alternate coverage
• Hospital Admitting Privileges or alternate Admitting ArrangementsCopy of current Drug Enforcement Administration (DEA) registration Certificate, and copy of state controlled substance certificate (if applicable)
• Copy of W-9
• Copy of Educational Commission for Foreign Medical Graduates (ECFMG) certificate, if applicable
• Curriculum vitae listing, at minimum, a five year work history (not required if work history is completed on the application)
• Signed and dated release of information form not older than 90 days
• Proof of highest level of education - copy of certificate or letter certifying formal post-graduate training
• Copy of Clinical Laboratory Improvement Amendments (CLIA), if applicable
• Disclosure of Ownership & Controlling Interest Statement
• Evidence of completion of Cultural Competency training

If applying as an individual practitioner or group practice, please submit the following information along with your signed participation agreement:

• A completed, signed and dated Credentialing application. If applying as an ancillary or clinic provider, please submit the following information along with your signed participation agreement:
• Hospital/Ancillary Provider Credentialing Application Completed (one per Facility/Ancillary Provider)
• Copy of State Operational License
• Copy of Accreditation/certification (by a nationally-recognized accrediting body, e.g. TJC/JCAHO)
• If not accredited by a nationally-recognized body, Site Evaluation Results by a government agency.
• Copy of Current General Liability coverage (document showing the amounts and dates of coverage)
• Copy of Medicaid/Medicare Certification (if not certified, provide proof of participation)
• Disclosure of Ownership & Controlling Interest Statement
• Other applicable State/Federal/Licensures (e.g. CLIA, DEA, Pharmacy, or Department of Health)
• Copy of W-9

If applying as a hospital, please submit the following information along with your signed participation agreement:

• Hospital/Ancillary Provider Credentialing Application Completed (one per Facility/Hospital/Ancillary Provider)
• Copy of State Operational License
• Copy of Accreditation/certification (by a nationally-recognized accrediting body, e.g. TJC/JCAHO) - if not accredited by a nationally-recognized body, Site Evaluation Results by a government agency
• Copy of Current General Liability coverage (document showing the amounts and dates of coverage)
• Copy of Medicaid/Medicare Certification (if not certified, provide proof of participation)
• Disclosure of Ownership & Controlling Interest Statement
• Copy of W-9

Once Iowa Total Care has received an application, it verifies the following information, at a minimum, submitted as part of the Credentialing process (please note that this information is also re-verified as part of the re-credentialing process):

• Current participation in Iowa Medicaid Enterprise
• A current Iowa license through the appropriate licensing agency
• Board certification, or residency training, or medical educationNational Practitioner Data Bank (NPDB) for malpractice claims and license agency actions
• Hospital privileges in good standing or alternate admitting arrangements
• Five year work history
• Federal and state sanctions and exclusions

Iowa Total Care will complete the credentialing process within 30 days following receipt of a complete credentialing application.

The Credentialing Committee is responsible for establishing and adopting as necessary, criteria for provider participation. It is also responsible for termination and direction of the credentialing procedures, including provider participation, denial and termination.

Committee meetings are held at least monthly and more often as deemed necessary.

Note: Failure of an applicant to adequately respond to a request for missing or expired information may result in closure of the application process prior to a committee decision.

To comply with accreditation standards, Iowa Total Care re-credentials providers at least every 36 months from the date of the initial credentialing decision. The purpose of this process is to identify any changes in the practitioner's licensure, sanctions, certification, competence, or health status that may affect the ability to perform services the provider is under contract to provide. This process includes all providers, primary care providers, specialists and ancillary providers/facilities previously credentialed to practice within the Iowa Total Care network.

In between credentialing cycles, Iowa Total Care conducts ongoing monitoring activities on all network providers. Staff will ensure that network providers have not incurred exclusions, licensure sanctions, illegal activity, or other negative indicators in between or prior to their standard re-credentialing through this monthly monitoring.

A provider's agreement may be terminated at any time if the Iowa Total Care Credentialing Committee determines that the provider no longer meets the credentialing requirements.

All providers participating within the Iowa Total Care network have the right to review information obtained by the health plan that is used to evaluate providers' credentialing and/or re-credentialing applications. This includes information obtained from any outside primary source such as the National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank, malpractice insurance carriers and state licensing agencies. This does not allow a provider to review peer review-protected information such as references, personal recommendations, or other information.

Should a provider identify any erroneous information used in the credentialing/re-credentialing process, or should any information gathered as part of the primary source verification process differ from that submitted by the provider, the provider has the right to correct any erroneous information submitted by another party. To request release of such information, a provider must submit a written request to the Iowa Total Care Credentialing Department at:

Iowa Total Care Credentialing Manager
7700 Forsyth Blvd.
St. Louis, MO 63105

Upon receipt of this information, the provider has 14 days to provide a written explanation detailing the error or the difference in information. Iowa Total Care Credentialing Committee will then include the information as part of the credentialing/re-credentialing process.

All providers who have submitted an application to join Iowa Total Care have the right to be informed of the status of their application upon request. To obtain status, contact Provider Services at 1-833-404-1061 (TTY 711).

Iowa Total Care may decline an existing provider applicant’s continued participation for reasons such as quality of care or liability claims issues. In such cases, the provider has the right to request reconsideration in writing within 14 days of formal notice of denial. All written requests should include additional supporting documentation in favor of the applicant's reconsideration for participation in the Iowa Total Care network. The Credentialing Committee will review the reconsideration request at its next regularly scheduled meeting, but in no case later than 60 days from the receipt of the additional documentation. Iowa Total Care will send a written response to the provider's reconsideration request within two weeks of the final decision.

Federal regulations set forth in 42 CFR 455.104, 455.105 and 455.106 require providers who are entering into or renewing a provider agreement to disclose:

• The identity of all owners with a control interest of 5% or greater
• Certain business transactions as described in 42 CFR 455.105
• The identity of any excluded individual or entity with an ownership or control interest in the provider, the provider group, or disclosing entity or who is an agent or managing employee of the provider group or entity.

Provider Relations Specialists are available to help address any questions related to the terms of your provider agreement or credentialing requests. Representatives are assigned to specific regions.