Credentialing Criteria

In order to evaluate a qualified Health Care Provider the following criteria must be met as applicable:

  • A current unrestricted state license, not subject to probation, proctoring requirements or any disciplinary action. A copy of the license must be submitted along with the application.
  • A valid DEA or CDS certificate, if applicable.
  • Education and training that supports the requested specialty or service.
  • Foreign-trained providers must submit an Education Commission for Foreign Medical Graduates (ECFMG) certificate or number with the application.
  • Board certification is required for all providers who apply as a specialist. Keystone First Community Health Choices requires that all specialists be board-certified or meet one (1) of the following exclusions:
    • Documented plan to take board exam.
    • An associate within the group practice that the provider is joining is board-certified in the requested specialty.
    • Demonstrated network need for AmeriHealth Caritas.
  • The following organizations are recognized for purposes of verifying specialty board certification:
    • American Board of Medical Specialties – ABMS.
    • American Osteopathic Association – AOA.
    • American Board of Podiatric Surgeons – ABPS.
    • American Board of Podiatric Orthopedics and Primary Podiatric Medicine – ABPOP
    • Royal College of Physicians and Surgeons.
  • Work history containing current employment, as well as explanation of any gaps within the last (5) years.
  • History of professional liability claims resulting in settlements or judgments paid by or on behalf of the provider.
  • A current copy of the professional liability insurance face sheet (evidencing coverage).
  • Providers who require hospital privileges as part of their practice must have a hospital affiliation with an institution participating with Keystone First Community HealthChoices. PCPs must have the ability to admit as part of their hospital privileges. As an alternative, those providers who do not have hospital privileges, but require them, may enter into a collaboration agreement with a provider(s) who is able to admit. CRNPs and CNMs must have agreements with the covering physician.
  • Adherence to the Principles of Ethics of the American Medicare Association, The American Osteopathic Association or other appropriate professional organization.
Providers