Apply for Credentialing
Durable Medical Equipment (Diabetic Supplies Only)
Dear Health Care Provider:
The following instructions will help you understand the information required to credential you for Home Durable Medical Equipment (Diabetic Supplies Only). 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 will not be processed and will be returned.
- A completed signed and dated application is a required legal document. For multi-site pharmacies – a corporate application with appropriate credentialing documentation for each site will be acceptable.
- Medicare/Medicaid verification is needed (if applicable).
Note: A current copy of the Medicare and Medicaid Remittance Advise 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 Blue Medicare HMO and Blue Medicare PPO networks Medicare certification is required.
- One of the following accreditation certificates is needed (note the exception for Pharmacies below):
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- The Community Accreditation Program, Inc. (CHAP)
- Accreditation Commission for Health Care (ACHC)
- The Compliance Team Inc's "Exemplary Provider Award Program"
- Commission on Accreditation of Rehabilitation Facilities (CARF)
- Healthcare Quality Association on Accreditation (HQAA)
- National Association of Boards of Pharmacy (NABP)
- The National Board of Accreditation for Orthotic Suppliers (NBAOS)
- American Board of Certification in Orthotics and Prosthetics (ABC)
- Board of Certification/Accreditation International (BOC)
Note: Non accredited Pharmacies must submit exemption letter from Medicare.
- A general liability malpractice insurance face sheet is required 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.