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Enrollment of Practitioners in South Dakota

Credentialing: Eligible and Exempt Practitioners

Wellmark assesses and validates the qualifications of its network participants to ensure members of the highest quality practitioners.

Beginning September 1, 2004, Wellmark will credential all newly contracting Iowa and South Dakota practitioners using Wellmark's NCQA-level credentialing program. Practitioners currently contracting with Wellmark (current contracting practitioners) who have not previously been reviewed under this program will be taken through the process over the next several years.

Practitioners Eligible for Credentialing

The following practitioners must be credentialed in order to be eligible for participation in any Wellmark network. Provider credentialing occurs every three years (as of July 1, 2001) and pertains to:

• Advanced Registered Nurse Practitioners practicing as
  - Certified Clinical Nurse Specialists
  - Certified Nurse Midwives
  - Certified Nurse Practitioners
  - Certified Registered Nurse Anesthetists
• Certified Independent Social Workers (CISW) (Wisconsin)
• Certified Social Worker PIP (CSW-PIP) (South Dakota)
• Chiropractors (DC)
• Doctors of Dental Surgery (DDS) (oral surgeons, maxillofacial surgeons, and oral pathologists)
• Doctors of Optometry (OD)
• Doctors of Osteopathic Medicine (DO)
• Licensed Clinical Social Workers (LCSW) (Nebraska, Illinois)
• Licensed Independent Social Workers (LISW) (Iowa)
• Medical Doctors (MD)
• Occupational Therapists (OT)
• Physician Assistants (PA)
• Physical Therapists (PT)
• Podiatrists (DPM)
• Psychologists (Ph.D., Psy.D., Ed.D.)
• Qualified Mental Health Professional (QMHP) (South Dakota)

Practitioners Exempt from Credentialing

The following practitioners are exempt from credentialing:

• Physicians* (specifically pathologists, radiologists, anesthesiologists, certified registered nurse anesthetists, and emergency room physicians) who practice exclusively within the inpatient hospital setting or a freestanding facility setting (such as mammography centers, urgent care centers and surgi-centers) and who are credentialed by a Wellmark participating facility.
• Hospital based specialists* (such as neonatologists or radiation oncologists) who provide care for members only as a result of the members being directed to a participating hospital (the provider is not listed in the directory), do not need to be credentialed provided they are credentialed by a Wellmark participating hospital. The same is true of those practitioners (such as physical therapists, occupational therapists, advanced registered nurse practitioners, etc.) who practice exclusively in these facilities.  However, in all cases, practitioners who practice exclusively within a community mental health center or within a freestanding substance abuse facility must be credentialed.
• Locum tenens practitioners.  Locum tenens practitioners are defined as those practitioners who are in place for 60 days or less in order to provide coverage for the absence of a participating practitioner.  
• Residents are not recognized practitioners; however, if a resident is moonlighting outside of his/her training program and has a full medical license (not a resident's license), the resident can be credentialed for the moonlighting situation. 
• Facility credentialing does not apply to hospital based departments (specifically dialysis units, birthing units, laboratory departments and radiology departments) that are not listed in the directory (those departments that are listed in the directory will be reviewed against the credentialing criteria).

*Note: Any practitioners wishing to be listed in the directory are required to be credentialed regardless of the exemptions above.

Questions?

If you have additional questions regarding credentialing information, please review the Frequently Asked Questions About Credentialing page or contact the Provider Application and Credentialing department by phone at 800-700-9137 or e-mail.

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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.