Frequently Asked Questions About Becoming a Participating Provider

Individuals with appropriate training, licensure, and certification who:

• Sign an AmeriHealth Caritas VIP Care Participating Provider Agreement (or join a group that has a Participating Provider Agreement with AmeriHealth Caritas VIP Care).
• Participate in the Pennsylvania Medical Assistance (MA) program and maintain a valid PROMISe™ provider identification number.
• View the full list of criteria required for participation.

To enroll in the Pennsylvania Medical Assistance program, go to the Department of Human Services (DHS) website.

Every request for participation in the AmeriHealth Caritas VIP Care provider network, whether as a primary care provider or as a specialist, is evaluated against the current need to serve and treat our membership in our coverage area.

For more information on specialties AmeriHealth Caritas VIP Care is actively recruiting for, please contact Provider Networking at 1-866-546-7972.

Providers must:

• Register with Council for Affordable Quality Healthcare (CAQH) and provide all required information.
• Or, if you prefer to follow the paper credentialing process, you must complete a Pennsylvania provider standard paper application (PDF) that includes your signature and the current date.
• Submit all licenses, Drug Enforcement Agency (DEA) certification, board certification, education and training information, and hospital affiliation information to CAQH or AmeriHealth Caritas VIP Care, which will verify your documents before making a credentialing or recredentialing decision.

As part of the application process, AmeriHealth Caritas VIP Care will:

• Conduct a site visit and medical record-keeping review upon initial credentialing for all primary care providers (PCPs) and OB/GYNs. Scores for these reviews must be 85% or greater.
• Request information on provider sanctions prior to making a credentialing or recredentialing decision. Information from the National Provider Data Bank (NPDB), Federation of State Medical Board (FSMB), Medicheck (Medicaid Program exclusions), HHS Office of Inspector General (Medicare exclusions), Federation of Chiropractic Licensing Boards (CIN-BAD), and Pennsylvania State Disciplinary Action report will be reviewed as applicable.
• Maintain the confidentiality of, and safeguard, the information received for the purpose of credentialing and recredentialing.

• After AmeriHealth Caritas VIP Care receives your credentialing application, it is reviewed for completeness. If pertinent information is missing, the application will be returned to you for completion or a Credentialing Coordinator may contact you and request the necessary information. After the initial review of the application, our Credentialing department verifies your credentials (e.g., license, DEA certification, board certification) and presents the information to the AmeriHealth Caritas VIP Care Credentialing Committee for a final determination on your inclusion in the network. Additionally, an office site visit, with medical record review, is conducted for all PCP and OB/GYN office locations to ensure that your office site and office standards are conducive to adequately treating AmeriHealth Caritas VIP Care members.
• You have the right to review the credentialing information collected by AmeriHealth Caritas VIP Care, with the exception of references, recommendations and peer review-protected information. When a discrepancy is identified between the information that you submitted and the information obtained during the verification process, the AmeriHealth Caritas VIP Care Credentialing department will contact you for explanation and/or correction.
• You have the right to appeal any credentialing or recredentialing denial within 30 days of receiving written notification of the decision.

The process normally takes about 90 days. You will be notified via letter that you have been credentialed by the plan, and will receive a second notice from the plan that includes your AmeriHealth Caritas VIP Care participating ID number. Once you receive the second notice, you may begin seeing AmeriHealth Caritas VIP Care members.

To check on the status of your credentialing application, simply call 1-800-642-3510, and press option 2. Follow the prompts to check on your credentialing application. You can also inquire about the status of your application and ask questions by emailing provider.credentialing@amerihealthcaritaspa.com.

After initial credentialing, AmeriHealth Caritas VIP Care providers must be recredentialed every three years.