Apply for Credentialing
Orthotics and Prosthetics (This includes all Orthotics and Prosthetics which will include Breast Prosthetics only)
Dear Health Care Provider:
The following instructions will help you understand the information required to credential your Orthotics and Prosthetics 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 application signed and dated 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:
- The American Board of Certification (ABC)
- The Board of Certification/Accreditation International (BOC)
- Commission on Accreditation of Rehabilitation Facilities (CARF)
- Community Health Accreditation Program (CHAP)
- HealthCare Quality Association on Accreditation (HQAA)
- National Association of Boards of Pharmacy (NABP)
- The Joint Commission (JCAHO)
- The Compliance Team, Inc.
- The National Board of Accreditation for Orthotic Suppliers (NBAOS)
- Accreditation Commission for Health Care, Inc. (ACHC)
- Medicare/Medicaid verification is needed (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 must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million occurrence/$3 million aggregate.