Credentialing

Facility Credentialing

Credentialing Criteria
(As applicable)

• Health Delivery Organization (HDO) Information Form [PDF]
• Current copy of valid license, as applicable to type of facility
• Accreditation certificate, as applicable
• Malpractice Liability Insurance certificate(s)
• Signed and dated attestation/release to obtain primary source verification for the organization
• Employer Identification Number (EIN) Letter

All HDO applications must not be older than 180 days at the time of the Credentialing Subcommittee meeting.

Recertification
Prior to initial participation and every three years thereafter, verification is performed for the following:

• Current, valid state license
• Current standing with state and federal regulatory agencies
• Current malpractice liability insurance and/or LPCF participation and
• Accreditation by a recognized body (JCAHO, AAAHC, CHAP) OR a completed on-site assessment
• Home health agencies must be accredited
• Hospitals must be accredited or have a site visit performed

Forms
Health Delivery Organization Information Form [PDF]

All facilities must complete the above form in order to be considered for network participation.
One of the following attachments may also be required depending on facility type.

• HDO Attachment A: Ambulance Company [PDF]
• HDO Attachment B: DME Supplier or Pharmacy [PDF]
• HDO Attachment C: Hospital or Ambulatory Surgical Center [PDF]
• HDO Attachment D: Urgent Care Clinic / Walk-In Clinic [PDF]

Applicable Organizations
We review our contracted health delivery organizations as required by regulatory agencies. This policy applies to:

Alcohol/drug rehabilitation centers
Ambulance companies
Ambulatory surgical centers
Comprehensive outpatient rehabilitation facilities
Durable medical equipment suppliers
Federally qualified rural health clinics
Home health agencies
Home infusion centers
Hospice centers
Hospitals
Independent laboratories
Lithotripsy/orthotripsy facilities
Long-term acute care centers
Orthotics and prosthetics facilities
Psychiatric hospitals
Radiation centers
Radiology centers
Rehabilitation centers
Renal dialysis centers (free-standing)
Skilled nursing facilities
State-owned psychiatric hospitals and laboratory and diagnostic centers
Urgent care centers

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