Medicaid Resource Page
State Medicaid Facts and Resources
Table of Contents
- Introduction
- What is Credentialing?
- Why Does Credentialing Take So Long?
- Who Sets the Standards for Medicaid Credentialing?
- Partner With Credentialing Experts
Introduction
The United States Medicaid system was created to provide comprehensive health care coverage to low-income individuals and families, to include pregnant women, elderly and people with disabilities who cannot afford healthcare.
This government run program is partially funded and primarily managed by each individual state government. Each state has the ability to set baseline standards determining eligibility and benefits, but the Federal Government sets baseline standards for all state Medicaid programs and provides a portion of the Medicaid funding for each state. Individual states are not required to participate in the Medicaid program, but since 1982, all states have participated.
Established in 1965, Medicaid was part of the Great Society set of programs during President Lyndon B. Johnson’s administration and expanded by the Affordable Care Act passed in 2010.
Initially, Medicaid only offered Fee for Service or Direct Service Program in the US whereby providers bill Medicaid for each service and the state or their fiscal intermediary pays the fee according to a pre-determined fee schedule. This payment method mirrors the commercial and Medicare fee/payment arrangement.
Initiated in the 1980’s, states were able to receive waivers from the Federal Government to create Medicaid Managed Care programs. Under Managed Care programs, Medicaid recipients are enrolled in a plan administered by a commercial health plan, which receives a fixed monthly premium from the state. The health plan is then responsible for providing for all or most of the recipient’s healthcare costs. Almost all states utilize some form of Managed Care program to provide coverage to a large portion of their Medicaid recipients. Twenty-six (26) states have contracts with various Managed Care Organizations. Almost 80% of Medicaid recipients nationwide are enrolled in Managed Care programs. In comparison to the Direct Fee For Service methodology, Medicaid Managed Care programs are more cost effective.
The above is brief description of why and what Medicaid was established to accomplish. Determining whether or not your practice wants to participate with Medicaid is a question that will have to be answered on a practice by practice basis. If your practice does decide to participate with Medicaid, then the practice and each of the individual providers will need to be credentialed and enrolled with your local state Medicaid. Once the practice/providers are enrolled with local State Medicaid, they can request credentialing and enrollment for the State Medicaid Managed Care programs if they choose. The intent of this piece is to try to create a comprehensive resource outlining the process of credentialing a group/provider with the various State Medicaid entities.
What is Credentialing?
Credentialing ensures health providers like doctors and nurses have the appropriate qualifications to deliver safe and effective care. The process involves an exhaustive, systematic evaluation of the professional’s background. Credentialing involves verifying:
- Education and training
- Work experience
- Certifications
- Valid medical licenses and board certification
- Malpractice history
Professionals undergo this process to prove they are competent and capable of providing a high level of care. Credentialing also maintains the integrity of healthcare institutions. Patients want to feel safe in hospitals and other facilities, and part of that is having staff they can trust.
Why Does Credentialing Take So Long?
- Primary source verification: Primary Source Verification is a critical aspect of the credentialing process. It involves obtaining information directly from original sources like licensing boards and educational institutions to confirm things like licenses, certifications, and degrees. Primary Source Verification is completed by the insurance payor once a credentialing application has been submitted and is easily one of the most time consuming activities conducted by the verifications department.
- Background checks: Mainly utilized by Medicare and state Medicaid programs, background checks are another critical component of the credentialing process. Most background checks require providers to undergo fingerprinting and involve assessing a provider’s criminal history, malpractice claims, disciplinary actions, and any other relevant information that may impact the ability to provide safe and ethical care.
- Peer or committee review: Some credentialing processes also include a peer review component. In this step, a committee of your peers will assess your clinical competence and professional conduct to ensure you meet the required standards of clinical practice and ethical behavior.
- Review and decision: A credentialing committee will start the review process after you submit your completed application and documentation. The panel will evaluate your qualifications, experience, and compliance with organizational or regulatory standards. This assessment can take 90 days, depending on the entity. If approved, you will have the privilege to practice or become eligible for participation in insurance networks.
Who Sets the Standards for Medicaid Credentialing?
The Centers for Medicare & Medicaid Services (CMS) sets the broad federal standards for Medicaid credentialing, and individual states establish their specific rules and requirements within those federal guidelines. States are responsible for running their own Medicaid programs, so they determine specific standards for provider networks, access, and enrollment processes, often including requirements to contract with managed care plans.
For more details on your state’s Medicaid credentialing criteria and processes, DoctorsManagement has created an extensive online repository of important Medicaid enrollment links, requirements, portals, Help, FAQs, contacts and list of Medicaid MCOs by state. You can access these resources by clicking on your state below.
Partner With Credentialing Experts
Whether you’re dealing with Government payors or commercial payors, credentialing requirements can be complex, but you can streamline the process by partnering with DoctorsManagement, LLC. You only need to complete an onboarding application, but our team will help you expertly meet all the various credentialing requests and tasks. We have an in-depth understanding of the process and can advise you on timelines and tips to make it smoother.
Receive a custom quote from us with payment options that work for you. We facilitate credentialing and enrollment, letting you focus on what matters most — caring for patients and building your business. We will keep you abreast of your progress with transparent communication, so you can rest assured the process continues moving.
Request a free quote via phone at 800-635-4040 or reach out online.
Contact
Provider Enrollment Contact Information:
- (888) 223-3630 (Nationwide Toll-Free)
- Hours (All times Central) – Monday – Friday 8 a.m. to 5 p.m.
- Supervisor: Melissa Gill – (470) 657-9770 Click here to email Provider Enrollment
Aetna
Alabama Coordinated Health Network (ACHN): This is a state-based network that includes several regional networks, such as:
Contact
For assistance with the APEP portal, please visit the Provider Enrollment site, or contact Provider Services at (602) 417-7670
Medicaid MCOs
CaliforniaState RequirementsPortalHelpFAQsContactMedicaid MCOs – Varies by countyAlameda Alliance for HealthAnthem Blue CrossBlue Shield of California Promise Health PlanCalVivaCentral California Alliance for HealthCommunity Health Plan of Imperial ValleyConcertoHealth PACE (InnovAge California PACE – Crenshaw)CalOptima HealthCenCal HealthCommunity Health Group Partnership PlanFamily Health Care Network PACEGold Coast Health PlanHealth Net Community Solutions , Inc.Health Plan of San JoaquinInland Empire Health PlanKaiser Permanente*Kern Family Health CareL.A. Care Health PlanMolina Healthcare of California Partner Plan, Inc. Mountain Valley Health PlanPartnership Health Plan of CaliforniaSanta Clara Family Health PlanSCAN Health PlanSpecialty Health Plans
Brandman Centers for Senior Care PACE
Center for Elders Independence (PACE)
Family Health Centers of San Diego – PACE
Family Health Care Network PACE
InnovAge California PACE – Sacramento
Loma Linda University Health (PACE)
Connecticut State RequirementsPortalHelpFAQsNAContactMedicaid MCOsConnecticut does not use managed care organizations (MCOs) for its Medicaid program; it is one of the few states that operates its Medicaid services entirely through a fee-for-service model. The state’s Medicaid program is known as HUSKY Health, which is administered by the state’s Department of Social Services.
Delaware State RequirementsPortalHelpFAQsContactCall Center Hours!8:00 a.m. – 4:30 p.m.1-800-999-3371Medicaid MCOsAmerihealth Caritas DelawareDelaware First HealthHighmark Health Options
State RequirementsPortalHelpFAQsContactLogin issues related to a locked account:
Email the IMPACT Login Helpdesk at [email protected]Issues with ILogin User accounts:
Email the Okta team at [email protected]Provider Enrollment issues:
Contact a Provider Enrollment Specialist at 1.877.782.5565. Medicaid MCOsAetna Better HealthBlue Cross and Blue Shield of IllinoisCountyCareMeridian Health PlanMolina Healthcare
IndianaState RequirementsPortalHelpFAQsContactMedicaid MCOsHealthy Indiana PlanAnthemCareSourceMDwiseManaged Health Services (MHS)Hoosier HealthwiseAnthem
Hoosier Care Connect
Indiana PathWays for Aging
Humana
IowaState RequirementsPortalNAHelpFAQshttps://hhs.iowa.gov/media/10487/download?inlineContactPhone: 1-800-338-7909 (option 2). Or if in Des Moines, call 515-256-4609 (option 2).You can also email our team directly at [email protected].Medicaid MCOsAmerigroup Iowa, IncIowa Total CareMolina Healthcare of Iowa, Inc.
Kansashttps://www.kancare.ks.gov/State Requirementshttps://portal.kmap-state-ks.us/Documents/Provider/KanCare/PE_Guide.pdfPortalhttps://portal.kmap-state-ks.us/ProviderEnrollment/EnrollmentCreateHelphttps://portal.kmap-state-ks.us/Help/HelpContentPopup?helpContentKey=ProviderEnrollment.Welcome&helpTypePrefix=UG&isModuleDDLDisplayed=trueFAQshttps://portal.kmap-state-ks.us/Documents/Content/KanCare/PE_Guide.pdfContact800–933–6593.Medicaid MCOsHealthy Blue
Kentuckyhttps://medicaidsystems.ky.gov/Partnerportal/home.aspxState Requirementshttps://www.chfs.ky.gov/agencies/dms/dpi/pe/Pages/prov-summaries.aspxPortalhttps://medicaidsystems.ky.gov/Partnerportal/home.aspxHelpchrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://medicine.uky.edu/sites/default/files/inline-files/Kentucky%20Medicaid%20-%20Provider%20Enrollment%20and%20Partner%20Portal.pdfFAQshttps://kyma.org/shared/content/uploads/2015/11/ORP-Frequently-Asked-Questions.pdfContactAssistance with Kentucky Medicaid Partner Portal Application (KY MPPA): If you experience technical issues, access issues (including Remote Identity Proofing), Credentialing Agent management issues, system errors, or have program/policy questions about Provider enrollment, please call the KY MPPA Contact Center.
Representatives are available Monday – Friday from 8 a.m. to 5 p.m. EST and can be reached at 1-877-838-5085.
- Extension 1: KY MPPA Technical/Access Issues
- Extension 2: Questions regarding Provider Enrollment or Program/Policy issues
For technical issues, the KY MPPA Contact Center can also be reached at [email protected].
Medicaid MCOs
Louisianahttps://www.lamedicaid.com/provweb1/provider_enrollment/newenrollments.htmState Requirementshttps://www.lamedicaid.com/providerupdate/provider_update_06_23.pdfPortalhttps://www.lamedicaid.com/account/login.aspxHelp https://www.lamedicaid.com/provweb1/Forms/forms.htm#userFAQshttps://www.lamedicaid.com/Provweb1/Provider_Enrollment/Provider_Enrollment_FAQ.pdfContactProvider Relations at 1-800-473-2783https://www.lamedicaid.com/Provweb1/Provider_Support/provider_supportindex.htm
Medicaid MCOs
Aetna Better Health of Louisiana
Humana Healthy Horizons in Louisiana
MaineState RequirementsInformation can be found in the Provider Maintenance User GuidePortalHelpchrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/Overview-Steps-to-Enroll-03082024.pdfhttps://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/State%20presentation%20Provider%20Enrollment%20Process%20Overview.pdfFAQsContact
- MaineCare Enrollment email box
- Provider Services Call Center: 1-866-690-5585, Option 2 for Enrollment Questions. TTY users dial 711.
- Provider Services Call Center: 1-866-690-5585, Option 7 for Revalidation Questions. TTY users dial 711.
Medicaid MCOs
Maine contracts directly with primary care providers and CCTs to manage care for Medicaid enrollees in the PCCM, PCMH, and health homes programs. Primary care providers are paid a monthly per-member case management fee in addition to the regular Medicaid fee-for service reimbursement. PCMHs, health homes, and CCTs receive per member per month case management fees from Medicaid and other payers participating in the multi-payer collaborative efforts. For NEMT services, Maine contracts with three brokers; Logisticare, MidCoast Connector (Waldo CAP), and Penquis CAP.
MichiganState RequirementsPortalHelphttps://www.michigan.gov/mdhhs/doing-business/providers/providers/medicaid/provider-enrollment/contact-provider-enrollmentMedicaid MCOsAetna Better Health of MichiganBlue Cross Complete of MichiganHAP CareSourceMcLaren Health PlanMeridian Health Plan of MichiganMolina Healthcare of MichiganPriority Health Choice
MinnesotaState RequirementsPortalHelpFAQsContactMHCP provides a free weekly Q&A session every Wednesday, from 1 to 2 p.m. A link to join the Q&A session is available on the MPSE Training webpage.Medicaid MCOs
MontanaState RequirementsPortalHelpFAQsContactProvider Relations at (800) 624-3958.Medicaid MCOsMontana does not have Medicaid managed care plans; instead, traditional Medicaid is administered directly by the state, which pays healthcare providers for services rendered. While many states use managed care organizations, Montana’s system is entirely government-run.
NebraskaState RequirementsPortalHelpFAQsContactFor more information about Maximus’ PDMS, call (844) 374-5022 or email [email protected]. For questions about how to enroll as a Nebraska Medicaid provider, call (402) 471-9018.Medicaid MCOsNebraska Total CareMolina HealthcareUnitedHealthcare Community Plan
New YorkState RequirementsPortalHelpFAQsContactMedicaid MCOsAmida Care, Inc. Capital District Physician’s Health Plan, Inc.Anthem HealthChoice HMO, Inc.Excellus Health Plan, Inc.
Health Insurance Plan of Greater New York, Inc.
Highmark Western and Northeastern New York Inc.
Independent Health Association, Inc.
MetroPlus Health Plan, Inc. (SNP)
Molina Healthcare of New York, Inc.
New York Quality Healthcare Corporation
North CarolinaState RequirementsPortalHelpFAQsContactCSRA Call CenterNameProvider EnrollmentAddress5444 Wade Park Ave, Wade IV
Raleigh, NC 27607
Telephone
Work
800-688-6696
Fax
855-710-1965
Alliance Health (Tailored Plan)
AmeriHealth Caritas North Carolina (Standard Plan)
Carolina Complete Health (Standard Plan)
EBCI Tribal Option
Healthy Blue (Standard Plan)
Healthy Blue Care Together(Children and Families Specialty Plan)
Partners (Tailored Plan)
Trillium (Tailored Plan)
United Healthcare Community Plan (Standard Plan)
VayaHealth (Tailored Plan)
Wellcare (Standard Plan)
North DakotaState RequirementsPortalHelpFAQsContactNoridian Healthcare Solutions
Phone: (877)328-7098 (toll-free) or (701)328-7098 option 1
Live support 8 a.m. – 5 p.m. CT, Monday – Friday. After-hours voicemail available.Medicaid MCOsNorth Dakota contracts directly with primary care physicians to manage care for Medicaid enrollees in the PCCM program.Program for All-inclusive Care of the Elderly (PACE)Medicaid Expansion MCO
OhioState RequirementsPortalHelpFAQsContactContact and online resources
- Phone: (614) 644-8199
- Website: Medicaid.Ohio.gov
IVR at 1-800-686-1516 and follow the prompts
AmeriHealth Caritas Ohio, Inc.
Anthem Blue Cross and Blue Shield
Humana Healthy Horizons in Ohio
OregonState RequirementsPortalHelpFAQsContactMedicaid CCOsAdvanced HealthAllCare CCOCascade Health Alliance
PacipicSource Community Solutions (Central Oregon, Gorge, Lane, Polk)
PennsylvaniaState RequirementsPortalHelpFAQsContactMA Providers Contact | Department of Human Services | Commonwealth of PennsylvaniaMedicaid MCOs
South DakotaState RequirementsPortalHelpFAQsContactMedicaid MCOsSouth Dakota currently administers its Medicaid benefits directly, rather than through a managed care model with private insurance companies. Therefore, there are no managed care plans to choose from, and the state directly pays healthcare providers for services rendered to eligible beneficiaries. Eligibility is determined by factors such as income, disability, and age.
TexasState RequirementsPortalHelpFAQsContactMedicaid MCOsAetna Better Health of TexasBlue Cross Blue Shield of TexasCommunity Health Choice
RightCare – Scott & White
Wellpoint (Formerly Amerigroup Texas)
Utah State RequirementsPortalHelpFAQsContactMedicaid MCOsMembers who live in Utah, Salt Lake, Davis, Weber, Box Elder, Cache, Iron, Morgan, Rich, Summit, Tooele, Wasatch, or Washington County, must choose a health plan. Members who live in any other county in Utah have the option of selecting a health plan or using the Fee for Service Network. The State of Utah currently has four managed care health plans/ACOs:Health Choice UtahHealthy U
WashingtonState RequirementsPortalHelpFAQsContactPhone: 1-800-562-3022, ext. 16137
Phones are open: Tuesdays and Thursdays from 7:30 a.m. to 4:30 p.m. (Closed from noon to 1 p.m.)
Phones are closed: Mondays, Wednesdays, and Fridays.
Online: HCA support portalMedicaid MCOs
Community Health Plan of Washington
Molina Healthcare of Washington
West VirginiaState RequirementsPortalHelpFAQsContact[email protected] or call (888)483-0793.Medicaid MCOs
Aetna Better Health of West Virginia
The Health Plan of West Virginia
Highmark Health Options
Wellpoint (formerly UniCare)
WyomingState RequirementsPortal HelpFAQsContactAny questions?If you have questions or need assistance, please click the button below to send an email.
Email address: [email protected]
Phone number: 1-877-399-0121
Wyoming’s Medicaid managed care program is called WYhealth, which focuses on wellness for eligible Medicaid recipients with complex medical conditions. This program is not a traditional managed care organization (MCO) that contracts with private insurance companies; instead, it is a state-administered program that provides care management services directly through a Nurse Care Manager.
America SomaoState RequirementsPortalNAHelpNAFAQsContact
American Samoa Medicaid Agency: For questions or guidance, you can contact the agency at the following:
Phone: 699-4777
Email: [email protected]
Medicaid MCOs
American Samoa does not operate a managed care model like the states; instead, it uses a unique Medicaid program approved under a 1902(j) Waiver that does not involve individual eligibility and enrollment. The program is administered directly by the government, with the state paying healthcare providers for services. Residents have access to care through the LBJ Tropical Medical Center and five primary health centers.
GuamState RequirementsPortalApplications are not yet available online, so you will need to obtain a provider application packet, either from the Guam Office of Public Accountability (OPA) website or a physical location, and submit it to the appropriate government agency. HelpFAQsNAContact
For Guam Medicaid provider enrollment, contact the Guam Department of Public Health and Social Services (DPHSS) or your managed care provider.
Medicaid MCOs
Guam does not currently operate under a mandatory managed care model for its Medicaid program. The program provides benefits through a fee-for-service model, and there are no specific managed care organizations listed as official partners. Instead, Guam’s Medicaid program is administered by the Guam Department of Public Health and Social Services.
Northern Mariana Islands – Domain blockedState RequirementsPortalHelpFAQsContactMedicaid MCOsThe Northern Mariana Islands (CNMI) does not have Medicaid managed care plans; it operates a fee-for-service (FFS) system with one hospital.
Puerto RicoState RequirementsPortalHelpFAQContact
- Phone: 787-765-2929
- Email: [email protected]
Medicaid MCOs
U.S. Virgin IslandsState RequirementsPortalHelpFAQsContactMedicaid MCOsThe US Virgin Islands (USVI) does not have managed care plans; its Medicaid program operates entirely on a fee-for-service basis.
