Apply for Credentialing
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 accredited.
- One of the following accreditation certificates required:
- 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)
- American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
- 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.
Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, 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.