Apply for Credentialing

Credentialing Instructions

Ambulatory Surgical Centers

Dear Health Care Provider:

The following instructions will help you understand the information required to credential your Ambulatory Surgical Center (ASC). To avoid delays associated with an incomplete credentialing application, please review this material carefully before attempting to complete the application. Fill in all required information completely and attach all required documents before submitting your application.

Upon completion of the credentialing process, your application will be presented to the Credentialing Committee for approval or denial. If denied you will be notified by certified mail. If approved, Network Management will contact you to finalize the contracting process and assign your effective date.

ALL APPLICANTS: Please note all fields must be COMPLETED or indicate NOT APPLICABLE (NA). All supporting required documents must be submitted or the application cannot be processed and will be returned.

• A completed signed and dated application for each site and each organization with a unique Federal Tax ID# is a required legal document.
• Ambulatory Surgical Centers must be either accredited, Medicare or Medicaid certified.
• One of the following accreditation certificates is needed (if applicable):
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • The Community Accreditation Program, Inc. (CHAP)
  • Accreditation Commission for Health Care (ACHC)
  • Accreditation Association for Ambulatory Health Care, Inc. (AAAHC)
• If not accredited, please provide a copy of the most recent CMS Review.
• A copy of the Division of Facility Services License is required for each site (or letter attesting to all covered sites).
  Medicare/Medicaid verification is needed for each site (or letter attesting to all covered sites) if applicable.
  Note: A current copy of the Medicare and Medicaid Remittance Advice Summary (RA) from the facility will meet this criterion. If you are not Medicare and/or Medicaid certified, please provide an explanation.
  Note: If applying for the PARTNERS National Health Plan (PNHP) network, Medicare certification is required.
• A general liability malpractice insurance face sheet is required for each site (or letter attesting to all covered sites), and must include current coverage dates, provider name, address and limits of coverage. Minimum coverage for all networks is $1 million occurrence/$3 million aggregate.
• If the provider answers yes to any questions on the application under section 1.G, the following information is required to process the application:
  • Number of cases less than $200,000
  • If greater than $200,000 actual or anticipated, include the occurrence date, settlement date, and nature of case.