How to Join a Health Plan’s Pharmacy Services Network: A Step-by-Step Guide
PART OF OUR UNDERSTANDING SERIES: Credentialing and Health Plan Enrollment for Pharmacists
By Nancy Jorgenson, CPhT, MTM Pharmacy Network Liaison, HealthPartners
Joining a health plan’s Pharmacy Services network, including Medication Therapy Management (MTM), is an exciting opportunity to make a difference in members’ lives. However, the process requires careful preparation and a clear understanding of what’s involved. Since not all plans make their participation requirements publicly available, it may be necessary to contact the plan directly to obtain this information.
While it can take several months to complete, following these steps will help you navigate the process with confidence.
Step 1: Make Sure You’re Ready
Before you even request a contract, it’s essential to ensure that you can meet the requirements set by the payor. These include:
- Providing consultations in a private and confidential setting
- Sending CMS-compliant letters for Medicare members
- Handling medical billing using the HCFA 1500 form
- Documenting SOAP notes within an Electronic Health Record (EHR) system
- Submitting all required reporting data
By ticking off these items, you’ll set yourself up for a smooth start to the process.
Step 2: Dive into Credentialing and Enrollment
The credentialing process marks the final piece of the puzzle for joining an MTM network. It’s worth noting that requirements can differ depending on the payor. Though time-intensive, this step is crucial for becoming part of the network. Accuracy and completeness in your application are key – taking the time to get it right pays off in the long run. The effort you invest now ensures a smoother transition into delivering Pharmacy services effectively.
Required Documents:
- Proof of licensure as a pharmacist in the state where the HealthPartners MTM program services are being provided.
- Documentation showing:
- Graduation from an accredited college of pharmacy on or after May 1, 1996, or
- Completion of a structured and comprehensive education program in pharmaceutical care management services, which must include both clinical and didactic components. The program must be approved by:
- The Board of Pharmacy of the state(s) where the pharmacist practices, and
- The Accreditation Council for Pharmacy Education (ACPE).
Step 3: Start the Contracting Process
Once you’re confident you meet the requirements, reach out to the payor. You’ll typically need to provide:
- A W-9 form
- A Disclosure of Ownership form
- A Provider Information form
After reviewing your documentation, the payor will draft a contract and send it to your organization for review. Once everything is finalized and signed, you’ll be officially on your way to the next step.
Wrapping It Up
Joining a health plan’s MTM network is a multi-step journey, but it’s a rewarding one. By staying organized and proactive, you’ll be well-equipped to navigate the process. Remember, each organization may have unique nuances, so don’t hesitate to ask questions and seek clarification when needed.
About HealthPartners
HealthPartners is an integrated, nonprofit health care provider and health insurance company located in Bloomington, Minnesota offering care, coverage, research, and education to its members, patients, and the community.
For more information about Pharmacy Profiles and its credentialing services, please visit www.pharmacyprofiles.com or contact Mark Pilkington, Executive Director, mpilkington@pharmacyprofiles.com, 202-429-7550.
