IOWA CREDENTIALING COALITION

Statewide Universal Credentialing Application Forms

September 2006

The Iowa Credentialing Coalition (ICC) released newly-revised versions of its Iowa Statewide Universal Practitioner Credentialing Application (ISUPCA version 1.3) form and its Iowa Statewide Universal Practitioner Recredentialing Application (ISUPRA version 1.1) form. These forms have been updated to reflect recommendations by users as well as members of the ICC. Most importantly, these forms provide for the NPI (the National Provider Identifier required by HIPAA effective May 23, 2007, with implementation schedules specified by Medicare, Medicaid, and commercial payers).

Persons should now use these newly revised versions of the ISUPCA and ISUPRA. The Iowa Statewide Universal Facility Credentialing Application (ISUFCA) form has not been changed.

The ICC credentialing application forms (ISUPCA, ISUPRA, and ISUFCA) and an Application Checklist are available through the IMS Web site in different electronic formats. ICC's credentialing application forms are copyrighted work products and protected to preclude alteration or revision by any user or other person.

Click here for access to the ICC's forms.

A medical practice or other user that would like to suggest changes to the ICC's credentialing application forms is encouraged to submit those suggestions or other comments to the ICC for its consideration. You may do so through IMS by contacting Traci Hellman at thellman@iowamedical.org. You may also submit comments to any member of the ICC.

The ICC is a voluntary cooperative initiative formed in 2000 and focused on easing administrative burdens associated with credentialing. Physicians and their medical practices increasingly are using the ICC's statewide universal credentialing application forms and many health plans and hospitals now accept the ICC's forms. ICC members continue to explore cooperative initiatives in the field of credentialing.

Current members of the ICC include: Iowa Medical Society, Iowa Osteopathic Medical Society, Iowa Medical Group Management Association, Iowa Hospital Association, Iowa Association of Medical Staff Services, University of Iowa Clinical Staff Office, Mercy Credentialing Service, Wellmark BlueCross Blue Shield of Iowa, Coventry Health Care of Iowa, Iowa Federation of Insurers, and Iowa Board of Medicine.