Why Choose EmblemHealth?

EmblemHealth and our companies have a single overriding mission: To provide affordable, quality health care to our members. We are proud of a tradition of providing helpful information and prompt, responsive service to our members, of giving your patients many plan options, and of our partnerships with health care professionals.

 

If you would like to join the thousands of physicians, dental professionals and clinicians who are partnering with EmblemHealth, please follow the instructions below to begin the credentialing process.

Join Our Network | EmblemHealth

Before You Apply

EmblemHealth has temporarily stopped accepting new provider applications for all networks unless the provider is joining a participating group. This pause affects HIP, EmblemHealth Plan, Inc. (formerly GHI), and EmblemHealth Insurance Company (formerly HIPIC).

 

IMPORTANT EXCEPTIONS: Our CBP Network, which primarily serves City of New York non-Medicare retirees, is open to new providers. Members can nominate their provider for entry, and providers can submit applications for their practice(s). Applications should be directed to: cityofnyretireesprovidernomination@emblemhealth.com. This includes providers wishing to serve members in the new NYC Medicare Advantage Plus Plan launching in 2022, though providers must also participate in our Commercial network.

 

Save time, paper, and postage!

EmblemHealth’s credentialing forms are now in a pdf format which allows you to download, fill out on-line, save, and submit by email.  Click here to learn more.

Step 1: Who Will Conduct My Credentialing?

EmblemHealth partners with various organizations to give our members the benefit of value-based care, administrative efficiencies, and specialized expertise. Where appropriate, EmblemHealth has entered into agreements with these partners to perform credentialing on EmblemHealth’s behalf. EmblemHealth has a stringent oversight process to ensure these partners meet our high standards. In certain circumstances, health care professionals are required to sign direct agreements with these partners and go through their credentialing processes.

 

Depending on your specialty or practice affiliation, you may need to apply for participation through one of EmblemHealth’s partners. 

 

Expand the following two tabs to see if your specialty or practice has a separate process in place that you will need to follow.

 

Based on your specialty, click on the link below to get more information about credentialing. If your specialty is not listed, download and complete the EmblemHealth credentialing documents under “Before You Apply.”

To see if your organization has been delegated for credentialing, please review this list. If your organization is on the list, please contact your administrator to discuss inclusion in EmblemHealth’s networks.

Step 2: What Forms Do I Need to Fill Out?

A. CAQH® Application

EmblemHealth requires all applicants for all networks to complete the Council for Affordable Quality Healthcare (CAQH) ProView® credentialing application form. If you do not have a CAQH number, please register with CAQH ProView. If you have any questions about how to obtain a CAQH number, please call CAQH at 888-599-1771.

 

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. You are required to validate the accuracy of the service and billing addresses before sending in your application. Please review our Council for Affordable Quality Healthcare’s (CAQH) Application Tips before submitting your next provider credentialing application to us.

 

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. EmblemHealth, the New York State Department of Health, and the Centers for Medicare & Medicaid Services periodically audit practices for appointment availability and provider accessibility. See our Access and Availability Requirements.

 

Review and complete all required information . If any required information is missing or incomplete, the application will be returned. The provider cannot be credentialed until a complete application is submitted.

 

Note: Please be aware that paneled primary care physicians must meet the minimum 16-hour office requirement and ensure your office hours are reflected accurately.

 

Save all changes to the CAQH application and re-attest. 

 

B. EmblemHealth Forms

While not required by CAQH, EmblemHealth requires certain information that you must submit with your ProView® Universal Provider DataSource (UPD) application for your “New Practitioner Application” to be processed. Please note: If you do not provide this information, your EmblemHealth application will be delayed or discontinued.


 

Credentialing and Recredentialing Forms

At a minimum, you will need to complete and submit the following forms for the credentialing and recredentialing processes. Dental professionals should use the forms on the Join Our Dental Networks page.


 

EmblemHealth Required Supplemental Forms

Supplemental Forms for Credentialing and Recredentialing

Below are supplemental forms you may also need. Dental professionals should use the forms on the Join Our Dental Networks page.

Step 3: Are My Documents Ready for Submission?

See Step 1 above to reconfirm which application process applies.

 

EmblemHealth requires all documents to be submitted electronically. Please do not mail in hard copies.

 

Please review this list to see if you have everything you need. Please make sure everything is filled out and accounted for. Missing or unclear information will only delay the credentialing process.

 

All Applications:

Groups submitting multiple doctors under one contract or a doctor(s) being added to an existing contract:

  • The Provider Credentialing Form questions regarding participation through a group must be completed and the TIN must match the one on the W-9.

 

No Admitting Privileges

  • 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.

Non-Physician Practitioners

Medicaid Providers Only 

  • Disclosure Certification Form 
  • Medicaid Compliance Certification 

29-I Facilities

Foster care agencies licensed under 29-I who will be caring for EmblemHealth Medicaid members must submit the following: 

  • Complete Organizational Credentialing Application
  • Current and valid 29-I license to operate (if applicable)
  • Valid NPI (National Provider Identifier)
  • Current Professional and General Liability coverage with minimum limits of $1 million per occurrence and $3 million aggregate
  • Confirmation by primary source that the provider is free of regulatory exclusion, preclusion, or debarment
  • Confirmation of Medicaid Enrollment (if contracted for Medicaid)
  • Confirmation of Annual Certification Statement for Provider Billing Medicaid 
  • Disclosure of Ownership for Medicaid
  • Accreditation (if mentioned on the Application)

PPO Dental Providers

PPO Dental Providers please follow the process found on the Join Our Dental Networks page.

  • EmblemHealth Dental Provider Application
  • W-9

You are now ready to submit your credentialing application by email as shown in Where Do I Send My Completed Forms?  

 

Step 4: Where Do I Send My Completed Forms?

Send Your Application by Email

Please send your completed application and agreement(s) to: CredentialingNYC@emblemhealth.com.

 

All applications for the PPO Dental Networks should follow the process found on the Join Our Dental Networks page, send your completed application and agreement(s) to: dentalproviders@EmblemHealth.com.

 

Please note: The email addresses above are for the submission of new applications only.  Status requests may be made to Provider Services at 866-447-9717. Please wait at least 45 days before inquiring on status.

 

Step 5: What Happens Next?

Our Credentialing team will reach out to you if additional information is needed. 

 

We recommend waiting at least 45 days before checking on the status of your application. To check status, call our Provider Services Line at 866-447-9717

 

If you have an account for our secure provider portal, emblemhealth.com, you can check your practice profile to see if your participation has changed.

 

CAQH requires providers to validate their information every 120 days. Recredentialing occurs every three years and relies on the CAQH application. Please keep your information current and ensure EmblemHealth remains an authorized plan.


Please be aware, during the credentialing process, practitioners maintain the following rights:

  • The right to review information obtained in support of their credentialing applications, excluding references, recommendations, or other peer review-protected material.
  • The right to correct erroneous information in written form to the credentialing department within 10 days of receipt of EmblemHealth's notification. This may include: actions on licensure, malpractice claims history, and board certification status.