Participating Providers and Networks
Becoming a Participating Provider
Providers may join the 1199SEIU Benefit Funds’ network by contracting directly with the Benefit Funds and successfully completing the credentialing process. All participating providers must be credentialed and comply with re-credentialing efforts every three years.
The Benefit Funds have established policies and procedures to credential providers so members have access to a wide selection of quality providers. The Benefit Funds’ credentialing criteria (see Credentialing Criteria, below) are based on the industry-recognized National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) criteria.
The Benefit Funds do not credential provider types or practitioners that are not licensed by New York State, where it is required.
We have partnered with the Council for Affordable Quality Healthcare (CAQH) to streamline the application process for practitioners. See Applicational Process for details.
At a minimum, eligible providers must meet the criteria listed below before they can participate in the 1199SEIU Benefit Funds’ network:
- A valid, current, unencumbered license to practice issued by the state education department within the state of practice
- Graduation from an accredited medical school, professional school, college of osteopathy or a foreign medical school recognized by the World Health Organization and completion of a residency program (foreign medical school graduates must submit an ECFMG certification if licensed after 1986)
- Current, active medical staff privileges (if applicable) in good standing at a participating hospital
- Evidence of at least five years of work history (“work” may include post-fellowship and military service)
- Professional liability insurance in the amount of $1 million per incident and $3 million aggregate per annum
- Current Drug Enforcement Agency (DEA) registration, where applicable
- For MDs and DOs only: Board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association
- Current and unencumbered participation in the Medicaid and Medicare programs or proof that such non-participation is entirely voluntary and not due to current or past debarment from the programs
- Absence of a history of disproportionately excessive professional liability claims in comparison to providers within the same specialty and same geographic location, including but not limited to lawsuits, arbitration, settlements, pending/open cases or judgements paid by or on behalf of the practitioner
- Absence of a physical or mental impairment or condition that may impede the provider’s performance of essential functions of their clinical responsibility; if the provider has a physical or mental impairment, they must submit adequate evidence that a physical or mental impairment or condition does not render the provider unable to perform the essential functions without threatening the health or safety of others
- Absence of a current chemical dependency or substance use problem; for an applicant with this history, the provider must submit adequate evidence that a past chemical dependency or substance use problem does not adversely affect the provider’s ability to competently and safely perform essential functions
- Absence of a history of professional disciplinary actions or absence of any other information that may indicate the provider is engaged in unprofessional misconduct (unprofessional misconduct can be defined as, but is not limited to, sexual misconduct (e.g., with patients), sexual harassment of their patients or fraudulent billing practices); an applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance
- Absence of a history of felony criminal conviction or indictment; an applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance
- Absence of falsification of the credentialing application, requested documents or material omission of information requested in the application
At the time of re-credentialing, participating providers must meet the following criteria:
- Absence of information to indicate a pattern of inappropriate utilization of medical resources
- Absence of substantiated member complaints; an applicant with this history must submit evidence that this history does not indicate probable future substandard professional performance
- All criteria applicable to initial credentialing must still be true
Depending on network needs, the 1199SEIU Benefit Funds may not be accepting new providers in certain specialties and geographic areas. Please check our website to confirm the specialties in which we are accepting additional providers. Practitioners interested in joining the Benefit Funds network must first complete and submit the Provider Recruitment Form, which serves as a request to participate in the Benefit Funds network. The request is then subject to the Benefit Funds’ network adequacy review to service our members in your geographic area, amongst other considerations. We will evaluate our current network need and let you know within 30-45 days whether or not you are eligible for participation and should begin the credentialing and contracting process.
Submit the completed form to the 1199SEIU Benefit Funds Provider Relations Department—Network Management via fax, (646) 473-7213, or email, [email protected].
We have partnered with the Council for Affordable Quality Healthcare (CAQH) to streamline the application process for practitioners. The Benefit Funds only accept initial credentialing and re-credentialing applications that are submitted via CAQH. You must attest to the accuracy of the information in your profile, in its entirety, every 90-120 days. (This is separate from being re-credentialed, which happens every three years.) Please visit the CAQH Provider Data Portal to register or to update your profile, and remember to designate the Benefit Funds as an authorized health plan to access your CAQH application. (Note: Please only begin the credentialing process via CAQH once we have responded to your request to participate and network need has been established.)
Facility and ancillary providers
Like practitioners, facility providers interested in joining the network must also complete and submit the Provider Recruitment Form. This request is also subject to the Benefit Funds’ network adequacy review to service our members in your geographic area, amongst other considerations. As with practitioners, we will evaluate our current network need and let you know within 30-45 days whether or not you are eligible for participation and should begin the contracting process. Once network need has been established, you will receive the Benefit Funds’ Ancillary Application Form, along with a participation agreement.
Providers must submit a completed Ancillary Application Form and a signed participation agreement, along with the documents listed below, to the 1199SEIU Benefit Funds Provider Relations Department—Contracting via fax, (646) 473-7213, or email, [email protected]
The completed application must contain:
- A tax identification certificate (Form W-9)
- A copy of a valid and current state operating certificate/business license, where applicable
- Evidence of malpractice insurance in the amounts of no less than $1 million/$3 million (and general liability insurance, where applicable)
- Malpractice claims history (if applicable)
- An executed participation agreement agreeing to accept the fee schedule as payment in full
For practitioners, facility and ancillary providers
The Provider Relations Department will review the completed application and have the information verified by primary sources before the application is submitted to the Credentialing Committee for final approval. It is important to submit all applications (including those sent through CAQH, for practitioners) and attachments promptly with current information to help ensure the Benefit Funds’ directories, website, billing system and member referrals all list your correct information.
Providers have the right to correct erroneous information submitted by another party or to correct their own information that may have been submitted incorrectly.Providers also have the right to review any information submitted in support of their credentialing applications, except for National Practitioner Data Bank (NPDB) reports, letters of recommendation and information that is peer-review protected. A provider must submit a written request to review their credentialing information.
The Benefit Funds’ Credentialing Committee meets monthly or as needed to review and approve new applicants. The Committee is chaired by the Benefit Funds’ Chief Medical Officer and includes participating providers in a variety of specialties. If you are interested in joining the Credentialing Committee and are a board-certified participating physician in the Benefit Funds network, you may send inquiries via fax, (646) 473-6087, or email, [email protected].
Incomplete applications will not be processed and will be closed. Providers should not assume participation. Only upon receipt of a welcome letter or other correspondence confirming an effective date of participation from the 1199SEIU Benefit Funds is that provider participating in the Benefit Funds’ network and able to see Benefit Funds members as a participating provider.
All providers must be re-credentialed every three years (at a minimum) to continue their participation with the 1199SEIU Benefit Funds. Re-credentialing allows us to re-evaluate qualifications and performance and helps ensure compliance with the Benefit Funds’ criteria.
Any fraudulent or erroneous information submitted to the Benefit Funds, including at the time of the original credentialing, can be cause for a provider to immediately lose their participation status with the Benefit Funds. Providers are obligated to immediately notify the Benefit Funds of changes to any information submitted as part of the credentialing and re-credentialing processes.
In certain instances, providers may be credentialed through “delegated credentialing,” whereby an outside entity authorized by the 1199SEIU Benefit Funds (generally a hospital or large physician group practice) will credential the provider. The entity still must sign a contract directly with the Benefit Funds and pass the Benefit Funds’ onsite auditing process. However, the Benefit Funds retain the final authority to approve, terminate or suspend a provider at their sole discretion. The Benefit Funds may delegate credentialing to contracted facilities, organizations or provider groups that demonstrate the ability, through a pre-delegation assessment, to meet the performance requirements of the Benefit Funds. Approved delegates may be evaluated annually, or ad hoc (with appropriate notice), to monitor continued compliance with the Benefit Funds’ current credentialing criteria.
Facility and Ancillary Provider Credentialing
The 1199SEIU Benefit Funds have established facility and ancillary provider criteria for evaluating and appointing providers to its network. This facility and ancillary provider application assesses and gathers appropriate certification data. It also verifies the extensive list of services provided by our facilities for areas such as behavioral health, mental health, substance use disorder, durable medical equipment, orthotics and prosthetics, home health/hospice, freestanding ambulatory surgery, rehabilitation and dialysis.
Please contact the Provider Relations Department to speak to one of our representatives about applying to be a participating ancillary provider at (646) 473-7160.
The Benefit Funds are committed to protecting the confidentiality of all provider information obtained during the credentialing process.
Please note that participating hospitals, treatment centers, ancillary facilities and group and individual providers should notify the Provider Relations Department of new providers joining and established providers leaving existing practices.