Providers: Credentialing

Application

Prospective providers must submit a Provider Application, which contains information on the provider’s education, training, professional background, licensure, DEA certificate (if applicable), evidence of Diagnostic Pharmaceutical Agent Certification, and/or Therapeutic Pharmaceutical Agent Certification. A CAQH application containing all required information is acceptable in lieu of the Avesis provider application.

Licensing
Providers must also submit a current license or have one present on CAQH, which we verify with the State Board of Optometry or the American Board of Ophthalmology and/or the American Medical Association.
Insurance
All participating providers must have professional liability insurance with minimum limits of $1 million/$3 million. Proof of insurance is required for participation.

Credentialing

Once we receive the completed application and required documents, it is submitted to the Avēsis Credentialing Committee for review. Upon approval, the provider will receive an executed Provider Agreement and information about our program in general and our specific plans. Upon becoming an active participant in our Provider Network you can download our Provider Manual at any time here.

Re-credentialing

Every three years, providers must submit an updated application, attestation, and current credentialing documents. This information can be submitted directly to Avesis or CAQH. The provider’s performance will be evaluated, with a review of any quality of care complaints. Quality of Care Management evaluates each practice and monitors the following:

Quality of care
Efficiency of care
Member satisfaction
Fulfillment of administrative requirement
Compliance with clinical standards

Provider Credentialing Forms

Dental

Dental Application Guardian Attestation and Authorization Release Form ADA Survey Georgia Medicare Application Illinois Application Kentucky Application Mississippi Application Louisiana Application Oregon Application W-9 Form

Vision

W-9 Form

Hearing

W-9 Form

Disclosure of Ownership Forms

Individual Business Entity KY Disclosure of Ownership NE Disclosure of Ownership

Non-Discrimination

Credentialing Committee decisions are never based on race, gender, ethnicity, nationality, age, sexual orientation, or patient type that composes the provider’s practice. This information is excluded from the provider roster presented to the Credentialing Committee, and the Committee members are bound to a code of ethics that prohibits any such discrimination from being a factor in their decision-making process.

All credentialing and re-credentialing decisions are subject to internal audit to monitor against any discriminatory outcomes. Annually, during policy review, Compliance will evaluate a set of committee materials to ensure they do not violate our non-discrimination policy. See Credentialing Committee Policy for further information.

Provider Rights

Providers have the following rights related to the credentialing and recredentialing process:

· Providers have the right to be informed of the status of their credentialing or recredentialing application. If a provider requests the status of their application, Avēsis will provide a description of the status within 30 calendar days of the request. This status will specify whether the application is in the verification process or the review and decision process, or whether a credential decision has been made.

· Providers have the right to review any information submitted in support of their credentialing decision, except for references, recommendations, or other peer review-protected information. The provider must submit a written request to review the information. The Plan will respond to the request via mail within 30 calendar days.

· Providers have the right to correct erroneous information obtained by Avēsis during the credentialing and recredentialing process. See Credentialing Verification CR-03 for the provider process to correct these errors.