Regence contracts with physicians, dentists, other health care and dental professionals and facilities to form provider networks essential for delivery of health care and dental services to our members. All providers must be credentialed before they can participate in Regence provider networks. Once credentials have been verified, a provider agreement is offered.

Provider Screening
The Patient Protection and Affordable Care Act (PPACA) requires State Medicaid agencies to comply with new provider screening requirements. Such screening procedures shall include licensure checks and may include, as the Secretary of Health and Human Services (Secretary) determines necessary:

• Fingerprinting
• Database checks
• Criminal background checks
• Unscheduled or unannounced site visits
• Other screenings the Secretary determines necessary 

Final regulations were published in the Federal Register on February 2, 2011.  The regulations are effective on March 25, 2011.

In addition, PPACA requires State Medicaid agencies to exclude from participation any individual or entity that owns, controls, or manages an entity that (or if such entity is owned, controlled, or managed by an individual or entity that):

• Has unpaid overpayments (as defined by the Secretary)
• Is suspended or excluded from participation under or whose participation is terminated under Medicare or Medicaid or
• Is affiliated with an individual or entity that has been suspended or excluded from participation under Medicare or Medicaid

Our Practitioner Credentialing Criteria for Participation and Termination was updated to January 1, 2011 to reflect this regulation. The Organizational Credentialing Criteria for Participating and Termination will be updated on March 1, 2011 with this information.

Contracting and credentialing steps:

Benefits of Participation

• Claim payments are made to you directly on a weekly basis.
• Provider consultants and dental representatives are available to help you and your staff.
• You are listed in Regence provider search (depending on the agreements you signed) made available to Regence members.
• You may provide input on Regence policies. Learn more.
• Regence members have financial incentives to seek care from you because their expenses will be limited to deductible, copayment and coinsurance amounts, and charges for non-covered items. They may also pay a lower deductible, copayment and/or coinsurance if care is provided by a participating or preferred provider.

Responsibilities of Participation
As a participating provider, you have agreed to:

• Cooperate with our Member Grievance and Appeal Procedures
• Bill Regence directly for covered services. Patients should not be asked to submit claims.
• Abide by Regence policy guidelines as it pertains to the determination of claims for our members.
• Direct patients to physicians, other health care professionals and facilities participating on the network used by the member’s plan whenever possible.
• Accept our Maximum Allowable Fees (depending on which agreements you have signed) as payment in full for covered services for all Regence and affiliated members.
• Your patients are only responsible for copayment, coinsurance and deductible amounts, and for services not covered by their benefit contract. Learn more about hold harmless and calculating Maximum Allowable Fees (PDF).
• Provide Regence with copies of members’ records (including X-rays), at no charge, when Regence requests records to make a claim determination. Provider must maintain records necessary to document the services for those claims submitted to us.
• Provide covered services to our members where such services are necessary and the provider is qualified to provide such services. In providing such services, the provider will meet the same standards of professional care that characterize the providers’ services to non-members.