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Frequently Asked Questions - Credentialing

Who can become a Keystone Mercy participating provider?

Is Keystone Mercy actively recruiting for my specialty?

What can I expect during the initial credentialing application process?

How soon after I submit my application can I start servicing and treating Keystone Mercy members?

How can I check the status of my credentialing application?

Once I have been credentialed, how often do I need to be recredentialed?

Who can become a Keystone Mercy participating provider?
Individuals with appropriate training, licensure and certification who currently:

Participate in the Pennsylvania Medical Assistance (MA) Program and maintain a valid PROMISe™ Provider Identification Number
Have one or more offices located in Bucks, Chester, Delaware, Montgomery or Philadelphia Counties

View the full list of criteria required for participation (see Attachment A)

To enroll in the Pennsylvania MA Program please visit: http://www.dpw.state.pa.us/PartnersProviders/MedicalAssistance/
HandbooksGuidesFormManuals/FAQ/003673180.htm

Is Keystone Mercy actively recruiting for my specialty?

Every request for participation in the Keystone Mercy provider network, whether as a primary care practitioner or as a specialist, is evaluated against the current need to serve and treat our membership in our five county coverage area.
For more information on specialties Keystone Mercy is actively recruiting, please contact the Provider Network Management Department at 1-800-521-6007.

What can I expect during the initial credentialing application process?
Providers must:

Complete a Pennsylvania Standard Application that includes signature and current date
Sign and date the attestation form as certification of the accuracy and completeness of the application information, which grants Keystone Mercy permission to contact outside agencies to verify or supply information submitted on the application.
Sign and date the Code of Ethics Affidavit.
Submit all licenses, DEA, board certification, education and training, and hospital affiliation information to Keystone Mercy, which will be verified prior to the credentialing/recredentialing decision.

As part of the application process, Keystone Mercy will:

Conduct a site visit and medical record-keeping review upon initial credentialing for all PCP, OB/GYN, and high volume specialist providers. Scores for these reviews must be 85% or greater.
Perform medical record reviews on all PCPs and high volume specialists upon recredentialing.
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.

What can I expect to happen after I submit my application:

After Keystone Mercy receives your credentialing application, it is reviewed for completeness. If pertinent information is lacking, the application will be returned to you for completion. 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 Mercy Credentialing Committee for a final determination on your inclusion in the network. Additionally, an office site visit, with medical record review, is conducted to ensure that your office site and office standards are conducive to adequately treating Keystone Mercy members.
You have the right to review the credentialing information collected by Keystone Mercy, 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 Mercy 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.

How soon after I submit my application can I start servicing and treating Keystone Mercy members?
The process normally takes about 90 days.

How can I check the status of my credentialing application?
To check on the status of your credentialing application, simply call Keystone Mercy's Provider Services at 1-800-521-6007.

Once I have been credentialed, how often do I need to be recredentialed?
Keystone Mercy providers are required to be recredentialed every three years.

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medicaid managed care, Pennsylvania, Philadelphia, Medicare Coverage, Find a Medicaid Health Insurance Plan, Find a Medicaid Provider, Doctor, Pharmacy, Pharmacist, What is Medicaid, How much does it cost to sign up for Medicaid, What is Medicaid Managed Care, How does Medicaid Managed Care Work?

Medicaid Managed Care Health Insurance, What is Medicaid, How do I sign up for Medicaid?

Medicaid Care, Managed Care or Medicaid, Manager, Manage Management of Care, and how to get health care. hospitals that accept Medicaid Managed Care patients

Find a Doctor in Pennsylvania, Find a Hospital in Pennsylvania, Who accepts Medicaid Managed Care

Healthcare Providers Pennsylvania, Medicaid Managed Care

Frequently Asked Questions - Credentialing