MMBS Credentialing Request Form

MMBS Credentialing Request Form
Provider Name:*

First NameLast Name
Providers Credentials:*
MD, DO, NP, PhD, LMSW, LPC, LMFT
NPI#*
Group Name if applicable:
Email*
example@example.com
Credentialing is the process by which health insurers verify the qualifications of healthcare providers, including mental health professionals, to ensure they meet the required standards to provide care under the insurer's network, before the provider begins treating patients under the insurer's coverage.

MMBS offers credentialing asssitance to providers as needed. This includes obtaining contracts, filliing out contracts, submitting contracts for processing to the insuarnce company and following up on the process of that contract until completed.

The term “Credentialing Assistance” means assistance with obtaining participation status with insurance companies and/or updating/changing Provider’s information with insurance companies (i.e. address changes). Credentialing Assistance is accomplished by using information provided by the Provider and is in no way a guarantee that the insurance(s) will accept the Provider as a participant with their company.

After applications are submitted the decision falls to the insurance company as to if the Provider is accepted into their network. Time frames for processing applications with each insurance company may also vary, each insurance company has a timeline for estimated time of completion for their process. MMBS has no way to rush this but does call periodically for updates to the applications to make sure the process is ongoing and no additional information is requried.

Credentialing Fees:

$200.00 per Provider per Application as needed.

$200.00 per Group Registration per Application as needed.

$100.00 per application for updating, changing or revalidating information per provider and per group.
AetnaASRBlue Care NetworkBlue Cross Blue Sheild of MichiganBlue Cross Complete MedicaidCarelonCignaHAPHumanaMclaren CommercialMclaren MedicaidMedicaidMedicare Part BMeridian Health Plan MedicaidMolinaOptum - United Health CarePriority healthOther
If Other Please list:
Individual ProviderGroupBoth an Individual Provider and GroupOffice Address UpdateMailing Address Update
Practice Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date*

MonthDayYear
Date
Signature*

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Please also fill out a Provider Information Form so that we have the information needed for completing credentailing. If we do not already have this on file we will send you the form upon receiving your request for credentialing assistance.

Once this request is submitted we will send you an invoice for the services needed. The Credentialing Assistance process will not start until payment is received.
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