Credentialing Instructions

Dialysis Facilities

Dear Health Care Provider: Residential Treatment Facility

The following instructions will help you understand the information required to credential your Dialysis Facility. 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 TAX ID# is a required legal document.
  • Dialysis Facilities must be either accredited or certified by Centers for Medicare and Medicaid (CMS).
  • One of the following accreditation certificates is needed (if applicable):
    • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
    • Accreditation Association for Ambulatory Health Care (AAAHC), if applicable.
  • A current copy of the Division of Health Service Regulation/ESRD Facility Survey Report is required.
  • Medicare/Medicaid verification is needed (if applicable).
    Note: A current copy of 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 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 is not currently accredited and answers yes to any questions on the application under section 1.G, an explanation is needed. The following information is required if question number C is answered yes:
    • 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
  • A copy of the CLIA certification or registration (Clinical Laboratory Improvement Amendments)/ACR (American College of Radiology) must be in all provider files.
  • A copy of the current Utilization Management Program is required.
  • A copy of the current Quality Management (Quality Assurance) Program is required.
  • A copy of the current Infection Control Plan to include infection rates and transfers from the Dialysis Center(s) to Acute Care Centers.
  • A copy of all current services provided at the facility.
  • A copy of the facility's one year of quarterly reporting of quality outcomes data for the following K/Dialysis Outcome Quality Initiative Indicators (K/DOQI):
    • Urea Reduction Ration (URR) = 65% 
    • Urea Kinetic Modeling (Kt/V) = 1.2 Kt/V delivered vs. prescribed dose 
    • Hemoglobin of 11-12 Grams 
    • Hematocrit > 33% for premenopausal females and pre pubertal patients and 37% for adult males and postmenopausal females 
    • Albumin of 3.5 to 5.2
      Note: 80% of all patients must meet the K/DOQI measures 

Get Acrobat To view PDF documents you need Adobe Acrobat Reader.