Apply for Credentialing
Home Infusion Therapy
Dear Health Care Provider:
The following instructions will help you understand the information required to credential your Home Infusion Therapy 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 will not 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.
- A copy of the Division of Health Service Regulation License and Board of Pharmacy Permit-Infusion Services is required for each site.
- Home Infusion Agencies must be either accredited or certified by Centers for Medicare and Medicaid (CMS).
- One of the following accreditation certificates is needed for each site (or letter attesting to all covered sites) if applicable:
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
- The Community Accreditation Program, Inc. (CHAP)
- Accreditation Commission for Health Care (ACHC)
- 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 Medicare 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 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 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.