Credentialing Criteria and Resources
Credentialing is required for all physicians who provide services to health plan members, as well as all other health professionals and facilities that are permitted to practice independently under state law and provide services to our members, with the exception of hospital-based health professionals.
Our credentialing process is designed to protect members and provide continued assurance that potential and/or currently participating providers meet the requirements necessary for the provision of quality care and service. The objectives of the credentialing program are to ensure that:
- Members who join our health plans will have their care rendered by appropriately qualified providers
- Each provider applicant has equal opportunity to participate
- Adequate information pertaining to education, training, relevant experience, and other credentialing criteria is reviewed by the appropriate individuals prior to approval or denial by the Credentialing Subcommittee
Note: If you are one of the types of providers listed below, you will need to join our network through one of our delegated vendors. Please check here for information about how to contact the appropriate delegated vendor directly.
- Behavioral health specialist/OMH- or OASAS-certified facility/substance abuse provider
- Dental provider
- Transportation provider
- Pharmacy provider
We participate with CAQH ProView. Practitioners are required to complete the CAQH ProView credentialing request and make their information available to us for use.
Note: Once your contract is validated, a VNS Health representative will provide a direct link for you to use to submit your request along with the supplemental documentation.
To be credentialed, you will need to include the following with your request:
- Board certification or board eligibility letter
- Copy of curriculum vitae/resume, including work history in a month/year format (gaps of 6 months or more must be accounted for)
- Copy of Drug Enforcement Agency and/or Controlled Dangerous Substances certificate
- Copy of current malpractice insurance face sheet with required minimum limits
- Summary of pending or settled malpractice cases and any necessary explanations
- Current hospital affiliation letter(s), collaborative agreement, or hospital admitting arrangement
- Current W-9
- HIV PCP attestation (for SelectHealth-contracted providers only)
What to Expect Next
Once your credentialing request has been submitted, you will hear from a credentialing specialist within 5 to 10 business days. You will receive one or more of the following:
- Signed and returned Provider Agreement
- An email informing you of any missing information or additional required credentialing documents needed for approval. If you do not supply this information within 10 business days, we will close out your request. You may reapply after.
- After a signed contract is received and your request is under initial review, you will receive an email informing you that your request is in the review process with the VNS Health Credentialing Department and by our Credentialing Subcommittee. It may take up to 60 days from the date of this email notification for the credentialing process to be completed. The Credentialing Subcommittee meets once during the last week of each month to review requests.
- Signed application and agreement
- Current unrestricted valid license to practice
- Current Federal Drug Enforcement Agency certificate (if provider type warrants)
- Relevant education and training
- Active enrollment and compliance with Medicaid (if applicable)
- Hospital affiliation (if applicable)
- Board certified or board eligible
- History of professional liability claims/settlements/judgements/disciplinary actions
- Professional liability insurance
- Must not be excluded or precluded from participation with Medicaid or Medicare programs
- Must not have opted out of participation with Medicare
During the credentialing process, practitioners have the following rights:
- To review information obtained in support of their credentialing applications, excluding references, recommendations, or other peer review–protected material
- To correct erroneous information, in writing
- To be informed of the status of their credentialing/recredentialing application
We require all practitioners to complete recredentialing every 3 years. At least 6 months prior to the end of the 3-year credentialing period, providers will receive a notice from the Credentialing Department requesting the practitioner to update CAQH ProView and provide any supporting credentialing documentation needed for review and approval.
It is essential that all requested documents are submitted in a timely fashion. Failure to do so may result in termination from the provider network. Practitioners who are terminated from the network will need to complete their initial credentialing application and go through the approval process again.
We require facility providers to complete the credentialing or recredentialing application. Depending on the provider type (listed below), supplemental documentation is requested and must accompany the application for review and approval.
Which Facilities Require Credentialing?
The following facility providers require credentialing:
- 29-I facilities (Voluntary Foster Care Agencies)
- Clinical laboratories
- Home health agencies (LHCSA/CHHA agencies/FI/CDPAS)
- Skilled nursing facilities
- Outpatient rehabilitation facilities
- Ambulatory surgery centers
- Dialysis centers
- Outpatient diabetes self-management training facilities
- Portable X-ray suppliers
- Diagnostic treatment centers
- Federally qualified health centers
- Durable medical equipment and medical supply vendors
- Radiology centers
- Chore and housekeeping services
- Environmental Modification Services/CFCO
- Personal emergency response system providers
- Social adult day care providers
- Home-delivered meals providers
- Transportation providers (car/livery service, ambulette, ambulance for non-emergency use)
- Adult day health care (medical day programs)
- Urgent care centers
Minimum facility qualifications and requirements for participating in our networks include, but are not limited to:
- Completed, signed, and dated facility credentialing application
- Malpractice insurance coverage (in accordance with contract)
- Current accreditation or acceptable site visit survey (with approved plan of corrections, if applicable)
- Meets applicable licensing requirements (state licensure/operating license/accreditation documents)
- Current proof of Medicare and/or Medicaid participation
- Acceptable history with regards to malpractice claims
We may choose to delegate provider credentialing and recredentialing to certain organizations that are subject to established policies and protocol. VNS Health Health Plans maintains the responsibility for ensuring that the delegated functions are being performed according to our standards. We have the right to approve, suspend, or terminate providers.
Delegated Roster Submissions
Delegated entities are required to submit monthly/quarterly provider rosters through this provider form.
The Delegated Entities Provider Roster Template consists of:
- Provider termination/add/update
- Location termination/add
- Demographic updates/removals
These documents will help you with the credentialing process and enable you to adhere to the proper requirements designated and outlined in our provider manual.
- Disclosure of Ownership & Control Interest Statement
- NYSDOH provider disclosure form
- NYSED NP Collaborative Relationships Attestation Form
- Hospital Admitting Arrangement form
- Collaborative Arrangement Form (mid-level practitioners only)
- Initial Attestation for HIV Primary Care Providers form (for SelectHealth providers)
- Annual Attestation for HIV Primary Care Providers form (for SelectHealth providers)
- American Disabilities Act (ADA) Attestation