Credentialing FAQ

Individuals with appropriate training, licensure, and certification who:

• Sign a Keystone First Community HealthChoices Participating Provider Agreement (or join a group that has a Participating Provider Agreement with Keystone First Community HealthChoices).
• Participate in the Pennsylvania Medical Assistance (MA) program and maintain a valid PROMISe™ Provider Identification Number (PPID).
• Have one or more offices located in these counties:
  • Bucks.
  • Chester.
  • Delaware.
  • Montgomery.
  • Philadelphia.

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

Every request for participation in the Keystone First Community HealthChoices provider network, whether as a primary care provider (PCP), specialist, or long-term services and supports (LTSS) provider is evaluated against the current need to serve and treat our membership in the county coverage area.

For more information on specialties Keystone First Community HealthChoices is actively recruiting, please contact our Provider Network Department at 1-866-546-7972.

Providers must:

• Register with CAQH and provide all required information.
• Or, if you prefer to complete the paper credentialing process, you must complete a Pennsylvania Standard Application (PDF) that includes signature and current date.
• Submit all licenses, Drug Enforcement Administration (DEA) certification, board certification, education and training, and hospital affiliation information to CAQH or Keystone First Community HealthChoices, which will be verified prior to the credentialing/recredentialing decision.

As part of the application process, Keystone First Community HealthChoices will:

• Conduct a site visit and medical record-keeping review upon initial credentialing for all PCPs and OB/GYNs. Scores for these reviews must be 85 percent or greater.
• Request information on provider sanctions prior to making a credentialing or recredentialing decision. Information from the National Provider Data Bank (NPDB), Health Integrity Provider Data Bank (HIPDB), 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 Keystone First Community HealthChoices receives your credentialing application, it is reviewed for completeness. If pertinent information is lacking, 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, board certification, etc.) and presents the information to the Keystone First Community HealthChoices 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 Keystone First CHC Participants.
• You have the right to review the credentialing information collected by Keystone First Community HealthChoices Pennsylvania Community HealthChoices, 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 Keystone First Community HealthChoices Credentialing department will notify you for explanation and/or correction.
• You have the right to appeal any credentialing/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 Keystone First Community HealthChoices participating provider ID number. Once you receive the second notice, you may begin seeing Keystone First Community HealthChoices Participants.

To check on the status of your credentialing application, call 1-800-642-3510, option 1. Follow the prompts to check on your credentialing application. You can also inquire about the status of your application or send questions to our secure e-mail address.

After initial credentialing, Keystone First Community HealthChoices providers are required to be recredentialed every three years.