Physicians of all disciplines are invited to participate including:

• MD
• DO
• DC
• DPM
• DMD

Physicians should complete the Texas Standardized Application (TSA). In addition to the TSA, the physician will also provide the following attestations upon initial credentialing:

1. Work history covering the last five years
2. A statement by the applicant regarding any limitations in ability to perform the functions of the position with or without accommodation
3. A history of loss of license and/or felony convictions
4. Lack of present illegal drug use
5. A history of loss of limitation of privileges, sanctions, or other disciplinary activity
6. Information on current professional liability insurance coverage
7. Information on whether the individual Provider will accept new patients from the HMO

Physicians must submit the names of at least two physicians who will provide cross coverage for applicant. Physicians who are selected by the applicant as providing cross coverage must be credentialed by Community and complete and submit an application form as well as fulfill requirements of 1-8 above.

Mid-Level Practitioners include the following disciplines:

• Nurse practitioner (RNP)
• Physician assistant (PA)
• Optometrist (OD) – Contact Envolve Vision
• Occupational therapist (OT)
• Physical therapist (PT)
• Speech therapist (ST)
• Audiologist
• Dietitian
• Psychologist (Ph.D.) 
• Licensed Social Worker (LMSW) 

Allied health professionals who care for Community Members exclusively under the supervision of a credentialed physician are not contracted individually by Community and will not be named in any Member publication. However, Community will confirm the validity of the allied health professional’s license, obtain primary verification that adequate training has been completed, and verify that no previous sanctions have been taken against the Provider by Medicare/Medicaid. Furthermore, Community will obtain documentation that the supervising physician has secured appropriate malpractice coverage for the employed practitioner if he/she is not independently insured.

Certified Midwife:

• Must maintain a current and active license to practice midwifery in the State of Texas
• Must provide written confirmation of having secured access to an obstetrical physician, as needed, which physician must be a participating Provider with Community, and have active hospital privileges with a facility contracted by Community, and located within the midwife’s practice area
• Must carry a minimum malpractice insurance in the amount of $100,000 per occurrence/$300,000 per policy period
• Must provide written attestation that all deliveries of low-risk Members will be completed in contracted birthing centers or hospitals
• Must provide evidence of a minimum of three years experience as a practicing midwife

Certified Nurse Midwife:

• Must be a registered nurse in the State of Texas
• Must maintain an active practicing certificate as a nurse midwife
• Must provide written confirmation of having secured access to an obstetrical physician, as needed, which physician must be a participating
• Provider with Community, and have active hospital privileges with a facility contracted by Community, and located within the nurse midwife’s practice area
• Must have active hospital privileges, as a nurse midwife with a facility contracted by Community
• Must carry a minimum malpractice insurance in the amount of $200,000 per occurrence/$600,000 per policy period
• Must provide a written attestation that deliveries of all Community Members will be completed in birthing centers or hospitals contracted by the Community
• Must provide evidence of a minimum of three years experience as a certified nurse midwife
• Must agree to request laboratory and/or diagnostic tests through assigned primary care physicians (PCP) or supervising OB/GYN contracted by Community

Health delivery organizations as defined by the National Committee for Quality Assurance (NCQA) include, but are not limited to:

• Hospitals
• Home Health Agencies
• Free-Standing Surgical Centers
• Skilled Nursing Facilities

The credentialing standards of participation for health delivery organizations have been developed in conjunction with NCQA and URAC standards to accomplish a judicious selection process in order to maintain and improve network selection. Community is not only responsible for the review and selection of accredited institutions, but also has the responsibility for assessing the safety of the physical environment and quality of health care provided to Members by non-accredited institutions. In the case of non-accredited institutions where the Health Plan is required to perform a site visit, the health plan may substitute a CMS review as a site visit if available. In the event that a CMS site visit is not available or was not conducted, pre-contractual site visits will be completed, based on accreditation status, i.e., non-accredited hospitals, home health agencies, skilled nursing facilities, and free-standing surgical centers. For organizations accredited by a recognized body, participation is determined primarily on the basis of accreditation status. A site assessment may be recommended at the discretion of the medical director. For non-accredited hospitals, home health/infusion therapy, skilled nursing facilities, free-standing surgical centers, and all other types of non-accredited organizations recruited to care for Community Members within their facilities, in addition to facility licensure and the review of policies and procedures for verifying the licenses of key personnel, a review of the care site using the attached assessment tool and interviews with key personnel or a CMS site review report, and evaluation of data collected such as quality improvement (QI) and utilization management (UM) plans, are the basis for determining participation with Community. In the event Community elects to contract with a health delivery Provider other than those aforementioned, Community will ensure, prior to contracting, that the Provider has met all state and federal licensure requirements and is free from any Medicaid/Medicare sanction activity. All health delivery organizations requesting participation with Community must either be Medicare-/Medicaid-approved Providers and suppliers or provide evidence of eligibility. Accreditation by a recognized body, i.e., JCAHO, AAAHC, and CARF, does not constitute a criterion for acceptance in the health plan’s network of health delivery organizations.

A. If the facility is accredited and proof of accreditation is provided, only the following items must be provided:

1. Completed, dated and signed application for participation in Community
2. Current copy of State licensure (HRS/AHCA)
3. Copy of current JCAHO, AAAHC and/or CARF accreditation report (whichever is applicable)
4. Malpractice and/or general liability insurance limits of $100,000/$300,000
5. Workers’ compensation coverage certification
6. Medicaid/Medicare certification number (attach copy of approval letter)
7. Copy/listing of all current State licenses for medical personnel or policy/ procedure on verification process of licenses for medical personnel
8. Federal DEA Registration for medical director
9. Resume/curriculum vitae and credentials of medical director
10. Resume/curriculum vitae of administrator/executive director or key management staff
11. Proof of Federal Tax Identification Number

If a site visit is conducted, in lieu of collecting licenses of all key personnel as part of the review, policies and procedures outlining the verification process may be reviewed on-site and documented.

B. If non-accredited or no proof of accreditation is provided, the following items are necessary: for hospitals, home health agencies/infusion therapy, skilled nursing facilities, ambulatory surgical center, and other free-standing centers:

1. Completed, dated and signed application for participation in Community
2. Current copy of state licensure (HRS/AHCA)
3. Malpractice and/or general liability insurance
4. Medicaid/Medicare certification number (attach copy of approval letter)
5. Number of certified Medicare beds (attach copy of letter from CMS)
6. Department of Professional Regulation Board of Pharmacy License (applicable if pharmacy is located at the facility or dispenses medication)
7. Copy of all current state licenses for medical personnel or policy/procedure on verification process of licenses for medical personnel
8. Federal DEA Registration for Medical Director
9. Clinical Laboratory Improvement Amendment, as applicable
10. Clinical Laboratory Law Certificate of Licensure, as applicable
11. Mammogram Certification (based on scope of services)
12. Biohazardous Waste Permit
13. Radioactive Materials License/Department of Health and Rehabilitative Services Office of Radiation Control (State Department License for Rehabilitation)
14. Radiology equipment registration
15. Resume/curriculum vitae and credentials of medical director
16. Resume/curriculum vitae of administrator, executive director and key management staff
17. Occupational License (County/City)
18. Proof of Federal Tax Identification Number
19. Directors and Officers Liability coverage or Errors and Omissions Policy.

If non-accredited, explanation for non-accreditation must be provided to include time frame in which the facility intends to seek accreditation.

Site visit assessment must be conducted for all non-accredited home health agencies/infusion therapy, hospitals, free-standing surgical centers, skilled nursing facilities.

C. For all other non-accredited facilities including, but not limited to: sub–acute facilities, durable medical equipment, physical therapy and rehabilitation center, diagnostic center, * dialysis center, **birthing center, etc., the following items are necessary:

1. Completed, dated and signed application for participation in Community
2. Current copy of state licensure (HRS/AHCA)
3. Malpractice and/or general liability insurance
4. Workers’ compensation coverage certification, as applicable
5. Medicaid certification number
6. Medicare certification number
7. Number of Medicare approved beds (attach copy of letter)
8. Department of Professional Regulation Board of Pharmacy License (applicable if pharmacy is located at the facility or dispenses medication)
9. Department of Professional Regulation Board of Pharmacy License (applicable if pharmacy is located at the facility or dispenses medication)
10. Department of Health and Human Services letter/certificate, as applicable
11. Letter from AHCA with provisions specific to the state of Texas (applicable to dialysis centers)
12. Copy/listing of all current state licenses for medical personnel or policy/ procedure on verification process of licenses for medical personnel
13. Federal DEA Registration for Medical Director, as applicable
14. Clinical Laboratory Improvement Amendment, as applicable
15. Texas Clinical Laboratory Law Certificate of Licensure, as applicable
16. Biohazardous Waste Permit, as applicable
17. Resume/curriculum vitae and credentials of medical director, as applicable
18. Resume/curriculum vitae of administrator/executive director or key management staff, as applicable
19. Current Occupational License (County/City), as applicable
20. Proof of Federal Tax Identification Number
21. Necessity of site visit for the above non-accredited facilities to be determined by the regional medical director
22. Facility has no known recognized accreditation body

**Birthing centers to provide protocol to include:

1. General policies
2. Risk assessment
3. Visit schedule and lab assessment
4. Interpartum, postpartum and newborn protocols
5. Family planning protocols and formulary
6. Medication policies and approved medication
7. Medical emergency/transfer procedures
8. Disaster/fire policies—(table of content of policies) satisfies this requirement).

Hospital-based specialties are identified as follows:

Radiology
Anesthesiology
Pathology
Neonatology
The specialty Providers listed above who practice exclusively in a hospital setting do not require completion of the same credentialing process as other independent practitioners, in accordance with NCQA and URAC guidelines. However, if the above mentioned specialists provide services to patients outside the hospital, e.g., skilled nursing facilities, outpatient surgery centers, urgent care centers, free-standing emergency rooms, or any other type of ambulatory setting, full credentialing must be completed prior to granting/renewing privileges of participation in Community’s delegated network.