Credentialing

Becoming a Participating Provider

In order to provide services to AmeriHealth Caritas Pennsylvania members as a participating provider, you must:

1. Be credentialed by AmeriHealth Caritas Pennsylvania (1-800-642-3510, option 2)
2. Sign a Participating Provider Agreement (contract) if not already contracted or if not part of an existing contracted group. Call 1-866-546-7972 for information.
3. Be enrolled in the Pennsylvania Medical Assistance program (more information below).

AmeriHealth Caritas Pennsylvania maintains and adheres to all applicable state and federal standards and regulations, Department of Human Services (DHS) requirements, and accreditation requirements governing credentialing and recredentialing functions. For more information, please call:

AmeriHealth Caritas Pennsylvania: 1-800-642-3510, option 2

The following types of practitioners require credentialing and re-credentialing:

• Allied health practitioners 
• Audiologist (AUD) 
• Certified Nurse Midwife (CNM) 
• Certified Registered Nurse Practitioner (CRNP)
• Doctor of Chiropractic (D.C.) 
• Doctor of Dental Medicine (D.M.D.) 
• Doctor of Dental Surgery (D.D.S.) 
• Doctor of Medicine (M.D.) 
• Doctor of Osteopathic Medicine (D.O.) 
• Doctor of Podiatric Medicine (D.P.M.)
• General dentists
• Occupational therapist (OT) 
• Pediatric dentists 
• Physical therapist (PT) 
• Public health dental hygiene practitioner (PHDHP)
• Registered dietitian
• School-based practitioners 
• Speech and language therapist 
• Therapeutic optometrist (O.D.) providing care under the medical benefit 

Credentialing criteria

To be evaluated as a qualified health care provider, you must meet the following criteria (as applicable):

• You must have a current unrestricted state license, not subject to probation, proctoring requirements, or any disciplinary action. A copy of the license must be submitted along with the application.
• You must have a valid Drug Enforcement Administration (DEA) or Controlled Dangerous Substances (CDS) certificate, if applicable.
• You must have education and training that supports the requested specialty or service.
• Foreign-trained providers must submit an Educational Commission for Foreign Medical Graduates (ECFMG) certificate or number with the application.

The following organizations are recognized by AmeriHealth Caritas for purposes of verifying specialty board certification:

• American Board of Medical Specialties (ABMS)
• American Osteopathic Association (AOA)
• American Board of Podiatric Medicine (ABPM)
• American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM)
• Royal College of Physicians and Surgeons
• You must show work history including current employment, as well explanations for any gaps within the past five years.
• You must show any history of professional liability claims resulting in settlements or judgments paid by you or on your behalf.
• You must provide a current copy of your professional liability insurance face sheet (evidencing coverage).
• If you require hospital privileges as part of your practice, you must have a hospital affiliation with an institution participating with AmeriHealth Caritas. Primary care practitioners (PCPs) must have the ability to admit as part of their hospital privileges. As an alternative, providers who do not have hospital privileges, but require them, may enter into a collaboration agreement with a provider(s) who is able to admit. CRNPs and CNMs must have agreements with the covering physician.
• You must adhere to the Principles of Medical Ethics of the American Medical Association, the American Osteopathic Association, or other appropriate professional organization.

Frequently Asked Questions about Becoming a Participating Provider

Contracting

Note: The credentialing process and contracting process can occur simultaneously.

Credentialing for providers participating with CAQH

AmeriHealth Caritas Pennsylvania has entered into an agreement with the Council for Affordable Quality Healthcare (CAQH) to offer our providers the Universal Provider DataSource that simplifies and streamlines the data collection process for credentialing and recredentialing.

Through CAQH, you provide credentialing information to a single repository, via a secure internet site, to fulfill the credentialing requirements of all health plans that participate with CAQH. Our goal is to have our all of providers enrolled with CAQH.

There is no cost to providers to submit applications and participate in CAQH.

• Register for CAQH.
• Grant authorization for AmeriHealth Caritas to view your information in the CAQH database.
• Send your CAQH ID number to AmeriHealth Caritas Pennsylvania (on the Application Checklist for Practitioners below).
• Submit the following documents to AmeriHealth Caritas via secure email with electronic signature or by fax to 1-717-651-1673.

Additional CAQH information

• CAQH Provider User Guide (PDF)
• Frequently Asked Questions About CAQH
• About Universal Provider DataSource (PDF)

Applications and application checklists

Each provider and facility MUST fill out the following documents in their entirety in order to initiate the credentialing process:

For providers who are registered with CAQH:

• Application Checklist for Practitioners (PDF)
• IRS Form W-9 (PDF)

For providers applying via paper (non-CAQH) process:

• Application Checklist for Practitioners (PDF)
• All documents as outlined on the Credentialing Checklist for Practitioners
• Pennsylvania Standard Application (PDF)
• IRS Form W-9 (PDF)

Hospital based only - providers providing services in the Hospital setting only

• Pathologist Anesthesiologist Radiologist Emergency Med Neonatologist and Hospitalist (PAREN) Data Entry (PDF)

For facilities:

• Application Checklist for Organizational Providers (PDF)
• All documents as outlined on the Credentialing Checklist for Organizational Providers
• Organizational Provider Credentialing Application (PDF)
• Ownership and Control Disclosure Form (PDF)
• IRS Form W-9 (PDF)

Submit all completed documents to AmeriHealth Caritas Pennsylvania via secure email with electronic signature or by fax to 1-717-651-1673.

Credentialing rights

After the submission of the application, health care providers have the following rights:

• To review information submitted to support their credentialing applications, with the exception of references, recommendations, and peer-protected information obtained by AmeriHealth Caritas Pennsylvania.
• To correct erroneous information. When information obtained by the Credentialing department varies substantially from information provided by the provider, the Credentialing department will notify the provider to correct the discrepancy.
• To be informed, upon request, of the status of their credentialing or recredentialing applications.
• To be notified within 60 calendar days of the Credentialing Committee or Medical Director review decision.
• To appeal any credentialing or recredentialing denial within 30 calendar days of receiving written notification of the decision.
• To know that all documentation and other information received for the purpose of credentialing and recredentialing is considered confidential and is stored in a secure location that is only accessed by authorized plan associates.
• To receive notification of these rights.

To request any of the above, providers should contact the AmeriHealth Caritas Corporate Credentialing department at: AmeriHealth Caritas, Attn: Credentialing Department, 200 Stevens Drive, Philadelphia, PA 19113.