This guide includes a brief overview of how to enroll an FQHC facility and a provider with insurance companies (Medicare, Medicaid, Tricare and Commercial plans such as UHC, Humana and Aetna) for the medical portion only. This article was put together by a credentialing specialist that took an FQHC through the credentialing process with the below insurance plans.  It should be noted that the process for Medicare and the commercial plans will be the same  across state lines but Medicaid will be state specific. 

Typically, the facility applications include a section to enter what type of services you will be rendering. If your FQHC clinic will be seeing medical, behavioral health and dental services, you would only need to submit the one application versus three separate to add the location rendering multi-specialty services. While only the medical insurances are listed in this example, the process would be the same for the mental health and dental commercial insurances. It should be noted that commercial insurances do not differentiate between FQHC and a group/clinic in enrollment.

Commercial insurances do not always have different applications for the different types of clinics (group/FQHC/etc.). Typically, the applications will include a section to specify which type of clinic you are. Commercial insurances do not always require a facility application and an individual provider application. However, there are always exceptions to this and it really depends on how your clinic wishes to be enrolled. Another thought to consider is how you will bill your claims to this insurance, for example, billing by facility would require enrolling the facility. If your FQHC has multiple locations, I highly recommended that an NPI number be requested for each location. By doing this, it will be much easier for end of the year reporting and UDS reporting. In turn, you will have to notify the insurances of adding a location/NPI to your group each time a new one is created. It is imperative that you always contact the insurance by phone, emailing your rep or going to their website to make sure that you have the most current application to complete before beginning. Neglecting this will add unnecessary delays to the insurance processing of your application.

In this guide, I have broken it down into sections by insurance companies. The examples provided are taken from a credentialing spreadsheet and instructions that I created for my credentialing assistant.  Please contact if you have specific questions about the enrollment process for your FQHC or if you’d like our assistance with the process.

Keep scrolling for a list of insurance plans and their unique process to enroll as an FQHC.

AETNA FQHC Credentialing

Facility

Contact the Aetna rep to request a facility agreement. You will need to state that your are an FQHC using one Tax ID for all of your facilities and providers. After the contract is signed you will be tying individual providers to this group. Note Aetna had us complete a group contract first. They then sent us an Addendum for each time we added a provider to tie them to us.

Individual Provider

First go to aetna.com. Under health care professionals select join the network. Select apply to join the network. Select medical professional under request an application (If is a mid- level they will be a PCP, do not choose the mid-level application). Complete the online application. After submitting the application, print out the thank you page. Write provider’s name on it and the date.

Second email the signed Aetna addendum along with the provider credentialing packet*, CAQH application, protocol (NP or PA only) to your rep.

*Because we are an FQHC, mid-levels are allowed to be PCPs.

AMERIGROUP FQHC Credentialing

Facility

This is a Medicaid Managed Care Organization for Kansas. It is a must that you contact the rep for the most current facility application, as it is updated often. This application is also used by all 3 MCOs for Kansas so pay attention to the mailing instructions as they are different for each company.

After you have completed the application, you will need to make 3 copies (one for each MCO) and have each signed in blue (this is so they know the signature is original or “fresh”). Along with the completed application you will need to submit a facility credentialing packet* with it. FEDEX overnight them to correct address for each MCO.

Individual provider

Complete Amerigroup roster add provider tab. Complete KS DOO. Email roster, DOO, provider credentialing packet*, protocol (NP or PA only) to Provider Relations Department.

BCBS FQHC Credentialing

Facility

For BCBS we enroll the group and the provider. You will complete the Provider Network Request to add a new group. You must also complete an application. It is the same application used for the provider. Only complete the sections that apply to your group. After the application is completed and signed, it can be emailed along with a facility credentialing packet*.

Individual provider

Complete provider network enrollment request and the application. Email both of these with the provider credentialing packet* and protocol (NP and PA only) to provider relations

CHARITABLE PROVIDER

Kansas has a state version of the Federal Tort Claims Act. You must first contact them to become a point of entry site for your facility. After the point of entry has been established to add new providers and tie them to our group, you complete the charitable provider form.

Regardless of where the provider will primarily see patients, the address needs to be your main location the original point of entry site. You must mail the original signed application, and then they will return it to you with their signature added.

HEALTHNET TRICARE FQHC Credentialing

Facility

Contact rep to inquire about a group/facility enrollment. They will send you the agreement and roster to complete. You will send the completed application back with the facility credentialing packet*.

Individual provider

After initial group enrollment to add a provider you will complete the Provider Information Form (PIF). Fax (using only the fax cover sheet provided in the PIF) along with the provider credentialing packet* and protocol (NP and PA only) to the fax number listed.

HEALTH PARTNERS OF KANSAS (HPK) FQHC Credentialing

This is a provider network. We send them the one application and they in return enroll us with these insurances. American Medical Security (AMS), Central Reserve Life, Cigna, Cigna/ GW (Great West), Continental General Insurance Company, Corporate Plan Management Inc, Cypress Benefit Administrators, GEHA – Government Employees Health Association, NAHGA Claims and Preferred Health Professionals.

Facility

Contact the rep you will set up a group contract. You will return the completed contract along with the facility credentialing packet*.

Individual provider

For the application you need the CAQH application printed out, HPK statement of attestation. Email these plus the provider credentialing packet* and protocol (NP and PA only) to the rep.

HOME STATE HEALTH 

Facility Credentialing

This is a Medicaid Managed Care Organization for Missouri. You must contact the rep for the correct facility application and roster. Return completed application, roster and facility credentialing packet*. Note: You can not submit this application until you have received the Medicare PTAN letter.

Individual provider Enrollment

Complete the MO DOO and the Home State Health Roster. Email these along with the provider credentialing packet* and protocol (NP and PA only) to the rep.

HUMANA FQHC Credentialing

Facility

Contact the rep to request the group application. Complete the application and roster. Return these along with the facility credentialing packet*.

Individual Provider Enrollment

Complete the provider demographic forms and the Humana roster. Email these along with the provider credentialing packet* and protocol (NP and PA only) to the rep.

FREEMAN FQHC Kansas Credentialing

This is a provider network. We send them the one application and they in return enroll us with these insurances: Anthem BCBS, Auxiant, Benefit Management Inc, Cerner Health Plan Services, Cigna Health Care of Kansas/Missouri, Comp Care of the Ozarks, Comp Results, Coresource, Corvel, Cox Health Services, FMH Coresource, Group Health and Work Comp, Healthcare Solutions Group, Healthlink, HealthScope Benefits, HealthSmart Benefits Solutions, International Medical Group, LCT Inc, MedPay Inc, Meritain Health, Native Care Health, Occumend-FPN Preferred Work Comp, OHRA Managed Care, Oklahoma Health Network, Premirecare Northwest, Qualchoice of Arkansas and USA Managed Care Organization.

Facility

There is not a facility/group agreement for this insurance.

Individual Provider Enrollment

Complete the pre-application and email to the rep along with the provider credentialing packet* and protocol (NP and PA only).

Wait for the rep to request the application. Then you will mail the CAQH application, CAQH attestation with the date you mail it out on it, provider credentialing packet* and protocol (NP and PA only) to the rep.

KS MEDICAID Enrollment

Facility

Go to https://www.kmap-state-ks.us/Public/Enrollment%20Application.asp. Select the Facility application. Note: you can not submit this application until you have received your Medicare certification letter showing you are officially an FQHC. The application must be signed in blue and have a facility credentialing packet* attached. Must FEDEX overnight this application, as it has to be completed before the MCOs can complete their applications. Note: you will not have to pay the application fee since you have already paid it to Medicare. You will just need to include the Medicare receipt with your application.

You will also have to complete a NON-FQHC application for the facility. We do this so that we may bill out the CLIA waived labs, be reimbursed for EKGs, ECGs and tele psych facility fees. Go to https://www.kmap-state-ks.us/Public/Enrollment%20Application.asp. Select the Standardized application not the facility application. You will only complete the sections that apply to the group. Note: you can not submit this application until you have received your Medicare certification letter showing you are officially an FQHC. The application must be signed in blue and have a facility credentialing packet* attached and have a letter attached explaining/detailing what your intentions are for this application (it is a special request).

This can be sent in the same package as the facility application.

Individual Provider Enrollment

Go to https://www.kmap-state-ks.us/Public/Enrollment%20Application.asp. Select the Standardized application.

Application must be signed in blue and mailed along with provider credentialing packet* and protocol (NP and PA only).

MEDICARE Enrollment for FQHC

This is the most important insurance for an FQHC. You must have this application completed and a PTAN issued before you are officially considered an FQHC and can begin your enrollments with your Medicaid plans. It is extremely important to be accurate and include all the necessary documentation on the first submission. Typically processing time for these applications can be up to 90 days. Every delay adds extra days on to the processing time, which in turn adds extra days on to your Medicaid applications.

Facility

For the facility you will complete multiple applications. FQHC clinics do not bill office visits like other clinics. You will bill office claims to Part A but labs and procedures are separated out to Part B. So we will need to complete both Part A and Part B applications. You have two options for applications, either paper applications or creating a group account on PECOS. It is highly recommend that the applications be completed on PECOS.

First you will create a PECOS account for the group. Second you will log int your account. Select my enrollments and new application to access the Part A and Part B applications. At the end of each of these applications, there will be a section to upload supporting documentation. This information will come from your facility credentialing packet*. Once you have submitted the application, you will receive a tracking number for the application. After you have completed the application, you will also have to pay the application fee. This only needs to be paid one time and then a copy made to submit with the other applications (Medicaid) requiring a fee.

Individual Provider Enrollment

If the provider has worked before coming to your clinic you will only need to complete and 855 R application unless you are adding a PA-C. If the provider is brand new, or has not been credentialed you will need to complete the 855I and 855R. If your provider is a PA-C whether new or not you will complete the 855 I application and no 855R.

To begin the applications you will login into PECOS select my enrollments and new applications. You will complete all necessary sections to add the provider. At the end of the application it will detail what supporting documentation needs to uploaded. This information will come from your provider credentialing packet*. After you have submitted the application, you will receive a tracking number for this application.

Note: These providers are not allowed: LMSW, LAC and LCAC, LCMFT and LMFT, LCPC, LPC, LMLP

MISSOURI CARES Credentialing

This is a Missouri Medicaid Managed Care Organization. Note: you can not submit this application until you have received your Medicare PTAN letter.

Facility Credentialing

Contact the rep for the contract. You will complete a contract and a roster. Return the completed application and roster along with the facility credentialing packet* to the rep.

Individual Provider Enrollment

Email the provider credentialing packet* and protocol (NP and PA only) to the rep.

MISSOURI MEDICAID Enrollment

Facility Credentialing

Go to https://peu.momed.com/peu/momed/presentation/providerenrollmentgui/ SelectionWindow.jsp select new provider enrollment application. Choose from list FQHC. Complete the online application, making sure that you print each section as you go. You will then fax the signature pages along with the facility credentialing packet* to the fax# on the signature page. You will also need to complete the MO DOO to include in this fax. Along with this application you will send the facility credentialing packet*. Note: You can not submit this application until you have received your Medicare PTAN letter.

Individual Provider Enrollment

Go to https://peu.momed.com/peu/momed/presentation/providerenrollmentgui/ SelectionWindow.jsp select new provider enrollment application. Choose from list the provider type you are enrolling. Complete the online application, making sure that you print each section as you go. You will then fax the signature pages along with the provider credentialing packet and protocol (NP and PA only) to the fax# on the signature page. You will also need to complete the MO DOO to include in this fax.

If the provider is already in enrolled, you will only need to complete provider update request form. If the provider is a mid-level, you will need to send the protocol with it.

MULTIPLAN Credentialing FQHC

Contact the rep to set up a group/facility account. You will return the completed application along with the facility credentialing packet* to the rep. In return you will be assigned a group number and given addendum sheet to attach to future individual adding of providers.

Individual Provider Enrollment

Complete CAQH attestation, history and attestation, TIN authorization. Attach group cover sheet and email all these along with the CAQH application, provider credentialing packet* and protocol (NP and PA only). Email to registrar@multiplan.com

OK MEDICAID Credentialing

Facility Enrollment

Note: You can not submit this application until you have received your Medicare PTAN letter.

Go to https://www.ohcaprovider.com/Enrollment/(S(lmmd3opmikvu0ytqcxl4cfrr))/Site/ Home/Home.aspx. You will need to select register here and create an account. Keep this safe as you will need this login/password anytime credentialing is required for this facility. Complete all sections. At the end of the application, it will request supporting documentation to be uploaded. This information is in the facility credentialing packet*.

After you submit the application online, it will give you a tracking number. All request to this application will only be identified with this tracking number.

Individual Provider Enrollment

You will only complete this for a provider who has a DEA. We bill by the facility not individual. We only enroll a provider who has a DEA so that they may write scripts.

Go to https://www.ohcaprovider.com/Enrollment/(S(lmmd3opmikvu0ytqcxl4cfrr))/Site/ Home/Home.aspx

You will need to select register here and create an account. We will need this anytime credentialing is required for the provider. Once you have created the login/password it will then redirect you to login and complete the application. A provider must work 20 hours or more to be a PCP, so only choose sooner care provider if less than 20 hours. If they are over 20 hours you will choose sooner care and Medicaid ordering/referring. This will require you to complete the uniform credentialing application in addition to the online application. At the end of the application it will tell you which supporting documentation is needed to be uploaded.

After you submit the application online, it will give you a tracking number. All request to this application will only be identified with this tracking number.

SUNFLOWER Managed Care Plan

Facility Credentialing

This is a Medicaid Managed Care Organization for Kansas. It is a must that you contact the rep for the most current facility application, as it is updated often. This application is also used by all 3 MCOs for Kansas so pay attention to the mailing instructions as they are different for each company.

After you have completed the application, you will need to make 3 copies (one for each MCO) and have each signed in blue. Along with the completed application you will need to submit a facility credentialing packet* with it. FEDEX overnight them to correct address for each MCO.

Individual Provider Enrollment

Complete the roster and KS DOO. You will email them along with the provider credentialing packet and protocol (NP and PA only) to network relations.

After you submit the email, they will reply that they have received the application. It will include a tracking number for this enrollment. We will need this for all follow up questions or concerns on this application.

UHC FQHC Credentialing

Facility Credentialing

This is a Medicaid Managed Care Organization for Kansas in addition to the commercial plan. It is a must that you contact the rep for the most current facility application, as it is updated often. This application is also used by all 3 MCOs for Kansas so pay attention to the mailing instructions as they are different for each company.

After you have completed the application, you will need to make 3 copies (one for each MCO) and have each signed in blue. Along with the completed application you will need to submit a facility credentialing packet* with it. FEDEX overnight them to correct address for each MCO.

Note: You can not submit this application until you have received your Medicare PTAN letter.

Individual Provider Enrollment with UHC

First you will have to call 877-842-3210 to start process. Listen to prompts and when it asks what type of provider you are enrolling you will have to say medical to get to a customer service rep.

Second you will send an email to hpdemo@uhc.com along with the Medicaid addendum, KS DOO, credentialing packet and protocol (NP and PA only). You must put the provider’s name and credentials in the subject line. In the body of the email you must put the following:

Name of clinic TAX ID 75-3002264

Provider’s name, NPI, specialty and degree Provider’s start date

Then you need to copy the body of the credentialing letter just the part that has the billing

address and the locations and put it in the email.

For Mid-levels you must put the supervising physician and their specialty.

After you submit the email, they reply that they have received the application. It will give you a tracking number for this enrollment. We will need this for all follow up questions or concerns on this application.

WPPA FQHC Credentialing

This is a provider re-pricing network. We send them the one application and they in return enroll us with these insurances: Allied Benefit Systems, Allied National, Assurant Health, Benefit Administrative Systems (BAS), Benefit Management , BMI – Joplin, Caprock Health Plans, CNIC Health Solutions, Coresource – Kansas City, Corporate Plan Management (CPM), Cypress Benefit Administrators, Employee Benefit Management Services (EBMS), Freedom Claims Management Inc (FCM), Freedom Life / Us Health Group, Group Services & Admin (GSA), Harrington Health (Fiserv), HealthSmart Benefit Solutions (Mutual Assurance Admin) , HMA, Healthcare Solutions Group (HSG), Kempton Group Administrators Inc, Med-Pay Inc., Medova Healthcare Financial Group/Lifestyle Health Plans, Medica, Meritain Health, National Foundation Life / Us Health Group, Regional Care Inc (RCI), Self Insured Services Company (SISCO), Starmark, The Benefit Group (TBG), The Loomis Company, Total Plan Services (TPS) and Trustmark Starmark Insurance.

Facility Credentialing

You must contact the rep to set up a group account.

Individual Provider Enrollment

Complete all of the following consent/release form, declaration of agreement and if an NP or PA either NP or PA control substance verification form. You email all these along with the provider credentialing packet* and protocol (NP and PA only) to provider relations.

*Provider Credentialing Packet should include the following information:

  • Credentialing letter
    • Every application that I submit, I attach a cover letter stating who we are, provider’s personal information (name, CAQH, NPI), billing address, locations provider will be at and what I intend to do with the attached
  • CV
  • State license(s)
  • DEA(s)
  • Board Certifications
    • If not board certified, you must include a letter/memo explaining Example: newly graduated and have applied to sit for boards.
    • If board certification is not a requirement to be licensed, you must include letter/ memo stating the provider will be working for an FQHC in an under privileged
  • NPI Enumeration letter
  • CEs for past 2 years
    • Hospital application only
  • CLIA
    • If only one CLIA for FQHC, must attach a memo stating that you are an FQHC and are only issued one CLIA for your entire FQHC and Tax It is issued to the main clinic under the medical director’s name. This covers all providers and locations.
  • W-9
    • If multiple locations, only attach the primary location the provider will be
  • Federal Tort Claims Act (Malpractice) with current

*Facility Credentialing Packet should include the following information:

  • Credentialing letter
    • Every application that I submit, I attach a cover letter stating who we are and what I intend to do with the attached
  • List of Provider that you are linking
    • Include their NPI number
    • State whether this is a primary or secondary location for the provider
  • State license
    • Medicaid application only
    • Two providers that you are
  • NOGA
    • Medicare and Medicaid only
  • NPI Enumeration Letter
  • CLIA
    • If only one CLIA for FQHC, must attach a memo stating that you are an FQHC and are only issued one CLIA for your entire FQHC and Tax It is issued to the main clinic under the medical director’s name. This covers all providers and locations.
  • Dept Treasury letter showing Tax ID issued
    • Medicare and Medicaid only
  • 501 (c) 3 letter from IRS
    • Medicare and Medicaid only
  • Federal Tort Claims Act (Malpractice) with current roster
  • W-9
    • For location you are adding Not every location your FQHC has.
  • Board of Directors roster
    • Medicare and Medicaid only
    • To include name/address/social security number/date of birth/date assigned to board.

Information that you will need in order to complete a Medicare/Medicaid facility application:

  • Legal Business Name
  • Doing Business Name
    • Note: This must match exactly what is stated on your
  • Location information of clinic
    • Note: This must match exactly what is stated on your
  • Effective date of the clinic
    • Note: This must match exactly what is stated on your
  • Tax ID
    • Number and effective date
  • Incorporation date
  • NPI number and effective date
  • Certification Number
    • This must be from the NOGA. Look for the Award No
  • Certification Number Date
    • This must be from the NOGA. Look for the section with the budget
  • Final Adverse History
    • You must enter all details, if you have an adverse
  • Authorized Official’s information
    • Name/Address/Social Security Number/Date of Birth/ Date that became Authorized Official.
  • Delegate Official’s information
    • Name/Address/Social Security Number/Date of Birth/ Date that became Delegated Official.
  • Board of Director’s information
    • Name/Address/Social Security Number/Date of Birth/ Date that became Board
Summary
Step-by-Step Insurance Credentialing Process for FQHCs
Article Name
Step-by-Step Insurance Credentialing Process for FQHCs
Description
Here is a great step-by-step overview of the credentialing process with the top commercial insurance payers, Medicare and Medicaid in a couple of states. The credentialing process is pretty similar regardless of state but you should check with your local network manager.
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Physician Practice Specialists
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