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 Martin's Point Generations Advantage and Martin's Point US Family 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.
Applicants must meet certain criteria to participate in a Martin’s Point network. A list of all required criteria can be found below.
A. Current and valid license for all states in which an applicant will treat a Martin’s Point health plan member or patient (See Provision to US Family Health Plan below)
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.*
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.**
H. Absence of loss or limitation of privileges or disciplinary activity.**
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.***
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.
* 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.
** 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 made the appropriate reparations and the sanction would not impact the ability of the applicant to provide quality care to Martin’s Point health plan members.
*** 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.
The US Family Health Plan is subject to the requirements set forth in the TRICARE Policy Manual, Chapter 11, Section 3.2, paragraph 2.1, which prohibits the plan from paying for services performed by providers who do not possess “an unrestricted license that is not subject to limitations on the scope of practice.”
The following circumstances in which a provider would be ineligible to participate with the plan are but not limited to:
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 the 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.
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 the initial credentialing, and at the time of re-credentialing (every three years). If a provider states that they are board certified in the contracted specialty, verification will be completed through an NCQA approved primary source.
Martin’s Point recognizes that there may be instances in which a provider is neither board certified in the contracted specialty, nor planning to pursue certification.
The provider may be credentialed if the criteria are met for one of the following exemptions:
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.
Other exemptions include:
1. 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.
2. Non-physician practitioners must have completed a master’s or post-master’s level program in his or her practicing specialty.
The applicant must complete continuing medical education (CME) every two years with an accumulation of 50 hours:
3. 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:
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 able to provide the necessary information.
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.
The following guidelines are followed when reviewing notifications and making appropriate decisions regarding a practitioner’s participation, and appeal rights will apply:
License Action |
Non-disciplinary action may include:
Actions not limiting scope of practice may include:
Restricted license:
Suspended or inactive license:
Sanctioned or excluded practitioners:
Martin's Point Health Care Action |
Non-disciplinary action may include:
Actions not limiting scope of practice may include:
Restricted license:
Sanctioned or excluded practitioners:
Suspended or inactive license:
*If a practitioner is terminated due to suspension, a request may be made to reenter the network without going through the initial credentialing process if the license is reinstated within 30 calendar days of the suspension. The provider (or 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.
Additional information about the appeals process can be provided upon request
For questions, contact [email protected].
MPHC has entered 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.
All practitioners have the following rights during the credentialing process. Requests can be made via telephone, e-mail or mail:
During the credentialing or re-credentialing 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 the 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
MPHC requires that each facility complete an appropriate application and provide supporting documents / information if applicable.
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.