Apply for Credentialing

Credentialing Instructions

Mobile X-ray (PARTNERS Only)

Dear Health Care Provider:

The following instructions will help you understand the information required to credential your Mobile X-ray. 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.
• One of the following accreditation certificates is needed (if applicable):
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • Council on Accreditation for children and family services (COA)
  • Community Health Accreditation Program (CHAP)
  • Continuing Care Accreditation Commission (CCAC)
• A copy of a North Carolina Business license is required.
• Medicare verification is required.

  Note: A current copy of the Medicare Remittance Advice Summary (RA) from the facility will meet this criterion. For Initial Credentialing will also accept letter of certification from Medicare.

• 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 (or letter attesting to all covered sites).
• 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.