Credential Your Providers Quickly and Accurately
This applies to:
- Community Health Centers
- Federally Qualified Health Centers
- Diagnostic and Treatment Centers
To help us credential new clinicians quickly, efficiently and accurately, your application must be complete and contain current information about the clinician(s) you seek to credential. Please review this checklist before submitting your next provider credentialing application to us.
Make sure your clinician(s) enroll with CAQH® and that his/her credentialing information is current on the Provider Application. Before submitting it to EmblemHealth, check to make sure the information is complete and up to date. You are required to validate the accuracy of the service and billing addresses before sending in your application.
At EmblemHealth, we validate the accuracy of your addresses through phone calls. Locations found to have inaccurate information will be denied participation. This also includes the accuracy of the service address. We will check that the provider takes patients at that address and that the phone number given is for scheduling patient appointments.
Review and complete all of the required information. If any of the following is missing or incomplete, the application will be returned. The provider cannot be credentialed until a complete application is submitted.
The items below items may not include all required fields for the CAQH system. This lists data elements that are frequently missing and that prevent an application from being processed.
- Information you must provide
- Section 1:
- Provider Type
- Date of birth
- All professional and other IDs and expiration dates
- Section 3:
- Primary Specialty for which you are licensed that you will be practicing
- Section 4:
- Primary Practice Location including the tax ID to use for this provider (group or individual). Please only list service locations to appear in provider directories; for which the provider practices and takes patient appointments.
- Must check the box to indicate electronic capabilities.
- Payment and remittance information must be provided – even if you check the box, you must provide the email address of the payee contact.
- Office hours
- Section 5:
Admitting arrangements Hospital Privileges
- You must be affiliated or have coverage arrangements with at least one participating hospital in order to be credentialed with EmblemHealth. Provider types not required to have hospital privileges are: acupuncturists, allergists, anesthesiologists, audiologists, chiropractors, dentists, dermatologists, geneticists, nutritionists, occupational therapists, optometrists, pathologists, physiatrists, podiatrists, radiologists, physical therapists, physician assistant, speech and language pathologists.
- If yes: all requested information must be completed
- If no: indicate how patients will be admitted, i.e., enter the covering provider’s name and email address. Please note: the covering provider must be participating with the same EmblemHealth network and admit to an EmblemHealth participating hospital.
- Professional liability insurance carrier – All requested information must be completed and up to date – with an active policy in place (must not be expired). Ensure completion of the professional liability insurance section including your name, “To” and “From” dates, policy number and coverage limits (minimum $1 million per occurrence/$3 million aggregate), or accompanying roster from the agency/carrier with policy number and coverage limits. CAQH needs to be updated with the current account number and expiration dates of coverage.
- Work history and references. Provide a full account of your work history for the past five years in a month/year format. This includes current employment if provider has already started with current practice. If you have had an employment gap of six months or more in your supporting documentation, you must submit an explanation as to why the gap occurred. This would include a six-month gap between completion of training and employment start date.
Upload current copies of the following items under “Documents” section of the CAQH application:
- Disclosure Questions
- If you have any open or closed malpractice cases within the last 10 years, provide an explanation regarding your malpractice claims history, including the reason for the claim(s) and their disposition.
Save all changes to the CAQH application and reattest. Please note: Attestations for EmblemHealth can't be more than 120 days old.
- NYS DEA certificate*
- NYS license registration certificate*
- Malpractice face-sheet/Certificate of Liability Insurance
- Signed & dated W9 for applicable TIN# - Please ensure a copy of the W-9 form applicable for the tax ID affiliated with each service location on your application is attached or uploaded as supplemental documentation. Please note: only one W-9 form is needed per tax ID.
- CAQH authorization and release form (must be signed within 120 days of the application submission)
Also remember to place a check mark in all applicable boxes and answer the questions to the checked box, if applicable).
EmblemHealth Required Application Documents
In addition to the CAQH application, EmblemHealth requires clinicians to submit additional documents as follows:
- Non-Delegated Application Spreadsheet
- Group Roster
- Covering Provider agreement (if no current hospital privilege is recorded in CAQH)
- This may include a Transfer Agreement between the group and hospital
- This may include a Linkage Agreement between the group and hospital
- PA credentialing application (addendum for Physician Assistants)
- NP credentialing application (addendum for Nurse Practitioners)
- NP Collaborative Relationships Attestation form (Applicable to NP’s with More than 3600 Hours)
- NP Collaborative Agreement (Less than 3600 Hours, if applicable)
- Signed/dated W-9
- ADA attestation (must use the EmblemHealth’s form) – one for each location (Please note: an ADA attestation is not needed for GHI PPO.)
|PA credentialing application (addendum for Physician Assistants)
||Download (PDF) |
|NP credentialing application (addendum for Nurse Practitioners)
||Download (PDF) |
* Item not needed but make sure you complete the section of the application by giving the ID numbers for your DEA certificate and NY State license certificate.
You are now ready to submit your credentialing application. Once all of the above is completed, email your participation request(s) to your EmblemHealth Representative.
Please note: Discontinue use of any Initial Application Credentialing Checklists you may have previously used. The Credentialing Checklist is for INTERNAL USE ONLY and will not be accepted.
The following Document Checklist will help you verify that you have attached all required documents to your email before sending.