Apply for Credentialing
Dear Health Care Provider:
The following instructions will help you understand the information required to credential your Specialty Pharmacy.
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.
- Board of Pharmacy Permit-Devise and Medical Equipment Permit is required
- Medicare certification is required.
Note: A current copy of the Medicare and Medicaid Remittance Advice Summary (RA) from the facility will meet this criterion.
- Commercial General Liability Insurance of at least 1 mil/3 mil.
- A copy of the CLIA certification or registration (Clinical Laboratory Improvement Amendments) if applicable.
- Accreditation by URAC