Molina Provider Credentialing Guide

Did you know Molina Healthcare is one of the major health insurance players, insuring 5.8 million individuals in the USA? It primarily focuses on providing health plans to government-funded programs, such as Medicare and Medicaid. 

Getting credentialed with it is a big step for healthcare practitioners as it enables them to start providing care services to its members. However, the journey to this is not as easy as it may seem, and the requirements vary from state to state. 

This guide will walk you through the entire Molina credentialing process, from the initial contact to the final contract. 

So, without further ado, let’s get started!

A Step-by-Step Guide to the Molina Credentialing Application

The following are the steps involved in the credentialing process for Molina:

Step 1: The Initial Contact

The first step for getting credentialed with Molina is initiating contact. However, note that the process and points of contact vary depending on the applying provider.

Discussed below are the instructions for various types of healthcare practitioners:

For Medical, Behavioral Health, and Ancillary Providers

You must begin your request for application by completing and submitting the Molina contract form to IAProviderContracts@MolinaHealthcare.com.

For Vision Providers 

If you are a vision provider interested in credentialing with Molina Healthcare, contact their vision vendor, March Vision Care. There are two ways to do it: either visit Marchvisioncare.com or call (844) 496-2724.

For Pharmacy Providers

You need to connect with Molina’s pharmacy benefits manager, CVS Pharmacy, if you are rendering services under the pharmacy benefit. You can do so by visiting its website, here.

However, if you are a pharmacy or a pharmacist providing immunizations/POCT or DME, then you must complete a contract request form and send it to IAProviderContracts@MolinaHealthcare.com. 

If you want to request participation for multiple pharmacists or a pharmacist with several service locations, email IAProviderContracts@MolinaHealthcare.com.

Step 2: Documentation Submission

The next step in Molina Healthcare credentialing is documentation submission. If Molina accepts your contract form, then their provider contracting department will connect with you and ask you to submit the following documents:

• Practitioner application (if the applying provider does not have an updated and attested CAQH profile)
• Health delivery organization credentialing application
• Provider agreement
• Provider information form
• W-9

Note: The requested documentation may vary depending on the provider type.

Step 3: Credentialing Review

Once all the required documents are submitted, Molina’s provider contracting and credentialing departments will work collaboratively to credential the applying practitioners and facilities.

You will be notified about your Molina credentialing application status via a notification.

Step 4: Contract Finalization

Now that you have successfully completed credentialing with Molina, the insurance company will countersign your provider agreement and also send you a copy. 

Molina Provider Credentialing Requirements

Molina Healthcare’s credentialing requirements vary across states. However, in this guide, we will only discuss the criteria for Florida. 

Geographical Requirements

Healthcare providers must practice or plan to practice within 90 days of submitting a Molina credentialing application in any area covered by the insurance company.

Medicaid Enrollment & NPI/APIN

Applying practitioners, including ancillary providers, must apply for the Medicaid program. Besides, you must have a valid National Provider Identifier (NPI) or an Administrative Provider Identification Number (APIN).

License and Malpractice

You must have an up-to-date and valid license in your specific specialty and the state where you want to provide care services to ensure timely Molina Healthcare credentialing.

Moreover, you must have professional malpractice liability coverage that meets Molina’s specific criteria.

DEA Certification

Another key requirement is to have a current and unrestricted federal Drug Enforcement Agency (DEA) certificate and Controlled Substances certification (if applicable) for the applying provider.

Training and Board Certification

If you are a podiatrist, oral surgeon, dentist, or physician (MD or DO), you must have adequate training in your area of specialty. Besides, you must confine your practice to the credentialed area when providing services to Molina members. 

There are two ways in which Molina Healthcare verifies you have adequate training:

Current Board Certification

The applying practitioner must hold a current board certification by a board recognized by any of the following:

• American Board of Podiatric Surgery.
• American Board of Medical Specialties.
• American Board of Oral and Maxillofacial Surgery.
• American Dental Association (specific to practice area).
• American Osteopathic Association.
• American Board of Podiatric Orthopedic and Primary Medicine (ABPOPM).

Successful Completion of a Training Program

Another one of Molina’s credentialing requirements for applying practitioners is to have completed a training program, i.e., accredited by one of the following organizations:

• Accreditation Council for Graduate Medical Education (ACGME) in the United States.
• American Osteopathic Association (AOA) in the United States.
• College of Family Physicians in Canada (CFPC).
• Royal College of Physicians and Surgeons of Canada.

Note: Molina specifies that all applying oral surgeons must have completed a training program in Oral and Maxillofacial Surgery accredited by the Commission on Dental Accreditation (CODA).

General Practitioner Eligibility

What happens when you do not have any current board certification and have not completed an accredited residency? If you have maintained a primary care practice in good standing for a minimum of five years, you can still request participation as a general practitioner.

Disciplinary History

At the time of submitting the Molina credentialing application, the applying practitioner must not have any pending or open investigations from a state or federal professional disciplinary body. These may include the Notice of Proposed Disciplinary Action, Statement of Charges, or the equivalent.

Exclusions and Sanctions

The applying healthcare provider must not be suspended, expelled, or excluded from any federal or state-funded program, such as Medicare and Medicaid, to ensure successful credentialing with Molina.

Felony Convictions

You are only eligible to apply for Molina Healthcare provider enrollment if you have not been convicted of a felony or pled guilty to a felony for a healthcare-related crime. Some examples of these include patient abuse, unlawful manufacturing and distribution of a controlled substance, and healthcare fraud.

Supervising Physician

What are the requirements for Nurse Practitioners (NPs) and Physician Assistants (PAs) who do not have a license to practice independently? They must have a plan with a supervising healthcare practitioner. The plan must be approved by the state licensing agency. Besides, the supervising physician must be credentialed and contracted with Molina.

Ethical and Legal Conduct

The Molina credentialing requirements have a specific rule related to the applying practitioner’s professional affiliations. It states that the insurance company may deem a healthcare provider ineligible if they work for a facility or a private practice that Molina previously denied or terminated.

This rule is left to Molina’s discretion. It means that even if an applying practitioner meets all other requirements, Molina can still reject their application.

Admitting Privileges

As per the policy, a specific group of practitioners must have admitting privileges or a plan for hospital admission. That is, these practitioners must have a way to admit Molina members to a hospital in the event of emergencies. 

There are two ways through which you can do it: (1) a formal arrangement with a credentialed Molina-enrolled practitioner who has admitting privileges, or (2) a hospital inpatient team.

The following is a list of practitioners who must have the admitting privileges for successful Molina provider credentialing:

• Physicians (MD or DO)
• Primary care practitioners
• Midwives
• Oral surgeons
• Podiatrists
• Any other practitioners as required by state law.

Below is a list of practitioners who are exempt from this requirement:

• Dermatology
• Occupational medicine
• Pain medicine
• Physical medicine and rehabilitation
• Psychiatry
• Sleep medicine
• Sports medicine
• Urgent care and wound management

Backup Physician Requirement for Midwives

Licensed midwives who perform deliveries outside a hospital setting must meet specific backup physician requirements for Molina Healthcare provider enrollment:

• They must have a formal, 24-hour arrangement with a Molina-credentialed and contracted OBGYN.
•  In rural areas where an OBGYN is unavailable, a family practitioner who provides obstetric care may serve as the backup physician.
• The backup physician needs to be within 30 minutes of the midwife’s office.

Challenges in Getting Credentialed with Molina

Discussed below are some of the common roadblocks that make the entire credentialing process more challenging and lengthy:

Inaccurate or Incomplete Application

It is one of the common reasons that delays the Molina credentialing process. A single error or missing information, such as a date or signature, can halt the credentialing process in its tracks.

Outdated CAQH Profile

Molina considers the applying practitioner’s CAQH profile as the primary source of verification. Thus, if your profile is not updated or contains expired licensing, work history, or malpractice insurance, it can also delay the process.

Administrative Delays

The Molina insurance credentialing process involves a comprehensive review process and multiple departments. Thus, you may encounter significant delays due to a high number of applicants, a lack of staff, and internal communication gaps.

Missing or Incorrect Documentation

Depending on the applying practitioner type, the Molina credentialing application requires a specific set of supporting documents. These may include copies of malpractice insurance, a DEA certificate, and a license. Thus, if you fail to provide a document or submit incorrect information, you will experience a setback.

Termination or Denial History

If you have a history of application rejection by the credentialing committee, then you cannot reapply immediately. The time to wait varies based on the rejection reason:

• You are not eligible to reapply for one year if the committee denied your application.
• You cannot request participation for five years if the committee terminated your application.

Best Practices for Molina Insurance Credentialing

Here, let’s take a look at some best practices to streamline your credentialing process with Molina Healthcare:

Carefully Complete Your Application

You should treat your Molina credentialing application like an official legal document. That is, you should carefully review and fill each field, and cross-check all details before submitting it.

Keep Your CAQH Profile Updated

You should strive to keep your CAQH profile up-to-date with all the latest information, such as work experience, licenses, certifications, and malpractice insurance.

Organize Your Documents

Another best practice that can save you a lot of struggle and streamline the Molina Healthcare credentialing process is creating a digital or physical folder of all required documents.

Proactively Follow Up

Once you have applied, proactively follow up with the contracting department on the status of your application if you do not receive an update within the expected timeframe. 

Fulfill Provider-Specific Requirements

Since each provider type has unique requirements, you should focus on understanding the specific steps and necessary documentation for your particular specialty.

Partner with MediBillMD to Streamline Your Molina Credentialing Process

This blog discussed the steps involved and key criteria for successfully getting credentialed with Molina. Hopefully, this guide will become your go-to resource. However, if you need professional help, feel free to outsource insurance credentialing services to MediBillMD.

Even though we only discussed Florida-specific requirements to keep the guide simple, we cater to credentialing requirements for providers across all 50 states of the USA. We have a team of credentialing experts who are well-trained and skilled to ensure the timely processing of applications, making MediBillMD one of the best medical credentialing companies.

Frequently Asked Questions