Credentialing

We contract with physicians, dentists, other health care professionals and facilities to form provider networks essential for delivery of health care and dental services to our members. All providers must be credentialed before they can participate in our provider networks.

We require all providers to meet our credentialing criteria prior to contracting and remain in compliance with that criteria at all times.

Providers must:

• Be licensed and physically located in the Asuris service area (See the Out-of-area virtual support providers information below for the exception.)
• Be licensed in both the state where the member is located, as well as where the provider is physically located

Dental providers
Dental providers must complete all credentialing and recredentialing applications through asurisdental.com.

Out-of-area virtual support providers
Our participating facilities or groups can employ out-of-area virtual support providers.

• We contract directly with the facility or provider group in our service area.
  • The participating facility or provider group must submit claims to Asuris for services provided by the out-of-area provider.
  • Asuris will reimburse the participating facility or provider group.
• We still require credentialing for the out-of-area virtual support providers.

This does not apply to:

• Individual out-of-area virtual support providers who do not have a physical location in our service area and who are not part of participating facility or provider group with a physical location in our service area
• Telehealth vendors that do not have a physical location in our service area.

You must include a copy of your CP 575 or 147C letter, obtained from the Internal Revenue Service (IRS), to complete your credentialing application. Note: Do not use your Social Security number for billing purposes.

• The CP 575 is generated by the IRS when an Employee Identification Number is granted. Replacement CP 575 letters cannot be generated; a 147C letter contains the same information as the original CP 575.

• Request a 147C letter by phoning the IRS at 1 (800) 829-4933 during normal business hours. You can elect to receive the 147C letter via fax or email.

• Complete the online application using the Council for Affordable Quality Healthcare, Inc. (CAQH) Provider Data Portal. Note: If you use this service to complete an application, please notify our Credentialing department by completing this CAQH profile notification form.

• Download an application (PDF) and return it along with required documents noted on the application. Submit your 147C or CP 575 by email or fax to 1 (888) 335-3002.

Notes:

• The Credentialing email is only to be used for the submission of initial credentialing or recredentialing applications.
• If you have changes to your practice information or location, do not submit a credentialing application. Notify us of your changes by completing the Provider Information Update Form.
• Behavioral health providers: If you have changes to your areas of clinical focus or modalities, please complete the Behavioral Health Practitioner Areas of Clinical Focus Form.
• CAQH is only to be used for initial credentialing or recredentialing. If you need to notify us of other updates, please use the Provider Information Update Form.

Visit asurisdental.com to join our networks, view resources and support.

Complete an Organizational Provider/Facility Credentialing/Recredentialing Application (PDF) and return it along with required documents noted on the application. Submit your 147C or CP 575 by fax or email.

Notes:

• The Credentialing email is only to be used for the submission of initial credentialing or recredentialing applications.

• Organizational providers that have changed ownership and are required to complete the site survey process by the state and Medicare must be initially credentialed under the new ownership. If the state and Medicare allow the acquisition without the application and site survey process, credentialing may not be required.

This applies to a practitioner who practices exclusively within a hospital, inpatient or free-standing facility setting.

Complete the Hospital and Free-Standing Facility Based Practitioner Information Form (PDF) and fax to 1 (888) 289-1313.

Please note: If you move from practicing within a hospital, inpatient or free-standing facility setting to a clinic setting, you will be required to submit a credentialing application.

Please also review our Behavioral Health Medical Policies and complete our Behavioral Health Facility Assessment form. Note: Completion of the Behavioral Health Facility Assessment form does not affect the credentialing process or the outcome of your credentialing.

The information you share on the form about your facility’s specialties and demographics served helps us fully understand the services available. Presenting those to our members allows them to make informed decisions about their health care and who they select for services.

Upon receipt of a completed credentialing application, we verify the information using national and state data sources. Incomplete applications will delay the process.

You will receive an email confirming receipt of your application and instructions for completing required onboarding tasks. These tasks include:

1. Registering for Availity Essentials
2. Enrolling for EFT
3. Verifying your tax ID by faxing a copy of your 147C or CP 575 to 1 (888) 335-3002

4. Signing agreement documents

Note: Providers who are joining an existing agreement for a contracted tax ID may not need to complete some tasks.

• Agreements will not be issued until successful credentialing and all required onboarding tasks have been completed.
• Within 10 business days of signing your agreement documents, you will be loaded to our system as a participating provider. You will receive an email notification that confirms your participation on our network(s) and includes your effective date of participation.
• If you are joining an existing agreement for a contracted tax ID, you will be added to that agreement and will not have to sign agreement documents. The tax ID owner will be notified of your network participation effective date.

• Claims submitted before your effective date of participation will be processed as out-of-network.

• If you are a newly credentialed provider joining an existing contracted group, upon the approval of your credentialing, the effective date of your participation will be the date your credentialing application is considered complete, which is determined as part of the credentialing approval process.

• If you are a newly credentialed new-to-Asuris provider, the effective date of your participation will be based on when your contract agreement is signed.

Learn more about the contracting process, including how to determine your effective date and how to sign up for eContracting.

You are eligible to be credentialed and contracted as a network provider if you are:

• Licensed in the Asuris Northwest Health service area, and
• Reside AND conduct telehealth services within our service area (home or clinic location), or

• Reside outside our service area but physically conduct telehealth services from a location within our service area (e.g., clinic setting).

If you reside and provide telehealth services at a location outside of our service area, we are unable to contract with you.

The Onboarding Tracker gives you at-a-glance status of your onboarding progress and includes completed and outstanding required tasks. View the Onboarding Tracker on Availity Essentials: Payer Spaces.

Other helpful reports are available on Availity Essentials: Payer Spaces>Asuris>Applications>Provider Reports-for your organization>Credentialing & Maintenance Reports:

• Credentialing Status Report - credentialing and recredentialing status information for providers in your organization
• Returned Centers for Medicare & Medicaid Services (CMS) Validation Roster - a copy of the CMS Provider Validation spreadsheet that you sent back to us

• Provider Roster - a copy of the Centers for Medicare & Medicaid Services (CMS) Provider Validation spreadsheet that we send to you

All credentialed providers must remain in compliance with credentialing criteria at all times and must complete the recredentialing process every three years to continue network participation.

Providers whose contract status has lapsed more than 30 days will be required to resubmit an initial credentialing application. Not having an active practice location is considered a lapse.

The recredentialing request is sent approximately three to six months prior to the recredentialing due date. All providers are expected to respond to this request in a timely manner. Upon receipt, the application is reviewed using national and state data sources. Additional information reviewed may include, but is not limited to, member complaints and quality improvement activities. You have the right to correct erroneous information submitted by another source. Please call the Provider Contact Center to learn more.

Notes:

• The Credentialing email is only to be used for the submission of initial credentialing or recredentialing applications.

• Failure to return recredentialing documentation in required timeframes will result in the removal from provider directories and termination of the provider's network participation. Providers who have their participation terminated must wait one year before reapplying for network participation.

After completing the recredentialing process, providers will only be contacted by the Credentialing department in the event of an adverse decision or conditional approval status. Providers must agree to these conditions in order for contracts to be maintained.

Providers who have been terminated from network participation, including adverse decisions due to quality reasons or altering conditions of participation have the right to appeal. Refer to the Provider Contract Termination Appeals process for additional information. Providers who leave a delegated entity must notify us and are subject to recredentialing guidelines.

Behavioral health facilities
In addition to completing information for your recredentialing, please review our Behavioral Health Medical Policies and complete our Behavioral Health Facility Assessment form. Note: Completion of the Behavioral Health Facility Assessment form does not affect the credentialing process or the outcome of your credentialing.

We require that all Indian or Tribal Health providers complete the credentialing process prior to contracting. These providers are required to complete the recredentialing process at a minimum of every three years.

Providers have the right to review information submitted to support their credentialing application, including review of information submitted from outside sources (for example, malpractice insurance and state licensing boards). Providers may also request information about the status of his/her application or reapplication. All requests should be submitted to Providers have the right to review all information submitted in support of their credentialing application, including data from external sources such as malpractice insurance and state licensing boards. To track the status of their application or reapplication, providers can use the Availity Onboarding tool. For any additional questions not addressed on Availity, providers can call the Provider Contact Center.

If we discover inaccurate or conflicting information in a credentialing application, we will notify the provider in writing of their right to dispute or correct the information, unless restricted by a verification source or prohibited by law. The provider must submit a detailed, written explanation of any clarifications or corrections within 15 business days of the request, following the instructions provided in the notification. Our credentialing staff will document receipt of corrected information in the provider's credentialing file.

Note: The Credentialing email is only to be used for the submission of initial credentialing or recredentialing applications.

You are required to verify your information in our directories every 30 days. Follow these steps to review your directory listing.

• Use the Electronic Contracting Registration form to add or update details about your legal contract signatory.

• Use our provider onboarding resource for guidance on completing required onboarding tasks.
• Visit the Onboarding Tracker on Availity Essentials for at-a-glance status of your credentialing application and onboarding progress.
• Read our step-by-step Guide to Contracting (PDF)
• Has a provider left or joined your practice? Complete our Provider Information Update Form.