Provider and facility applications

Please include the following documents with your application:

•  A copy of a North Carolina license
•  Proof of Medicare certification
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks Medicare certification is required.

A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage ($1 million per occurrence / $3 million aggregate) or letter attesting to all covered sites.

Infusion Agencies must be either accredited or certified by Centers for Medicare and Medicaid (CMS) – we will accept a site survey conducted within the past 3 years. 

Please include the cover letter and follow-up letter (if applicable):

• One of the following accreditation certificates is needed for each site (or letter attesting to all covered sites) if applicable:
  • The Joint Commission (TJC)
  • The Community Accreditation Program, Inc. (CHAP)
  • Accreditation Commission for Health Care (ACHC)
• Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable.
  • Note: A current one page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks Medicare certification is required.
• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.
• On the application form, if the facility answered yes to any questions under section 1.G, an explanation is needed. The following information is required if question number C is answered yes:
  • Number of cases less than $200,000
  • If greater than $200,000 actual or anticipated, include the occurrence date, settlement date, and nature of case.

Please include the following documents with your application:

• Ambulatory Surgical Centers must be accredited. One of the following accreditation certificates is required:
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • The Community Accreditation Program, Inc. (CHAP)
  • Accreditation Commission for Health Care (ACHC)
  • Accreditation Association for Ambulatory Health Care, Inc. (AAAHC)
  • American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
• A copy of the Division of Facility Services License is required for each site (or letter attesting to all covered sites). 
• Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
• A general liability malpractice insurance face sheet for each site (or letter attesting to all covered sites). It must include current coverage dates, provider name, address and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

Please include the following documents with your application:

• Birthing Centers must be accredited. One of the following accreditation certificates is needed:
  • The Joint Commission (TJC)
  • Accreditation Association for Ambulatory Health Care, Inc. (AAAHC)
  • Critical Access Certification for hospitals
  • Commission for the Accreditation of Birth Centers
• A copy of the Division of Health Services regulation license is required for each site (or letter attesting to all covered sites) if applicable
• A general liability insurance face sheet for each site (or letter attesting to all covered sites). It must include current coverage dates, provider name, address and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.
• A copy of the policy and procedure for coverage arrangements with a participating provider and hospital, in the event of an emergency situation is required.

Please include the following documents with your application:

• Dialysis Facilities must be either accredited or certified by Centers for Medicare and Medicaid (CMS). One of the following accreditation certificates is needed (if applicable):
  • The Joint Commission (TJC)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • National Dialysis Accreditation Commission (NDAC)
• A current copy of the Division of Health Service Regulation / ESRD Facility Survey Report
• Medicare verification is needed (if applicable)
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.
• In the application, if you've answered yes to any questions under section 1.G, an explanation is needed. The following information is required if question number C is answered yes:
  • Number of cases less than $200,000
  • If greater than $200,000 actual or anticipated, include the occurrence date, settlement date, and nature of case
• A copy of the CLIA certification or registration (Clinical Laboratory Improvement Amendments) / ACR (American College of Radiology) must be in all provider files
• A copy of the current Utilization Management Program
• A copy of the current Quality Management (Quality Assurance) Program
• A copy of the current Infection Control Plan to include infection rates and transfers from the Dialysis Center(s) to Acute Care Centers
• A copy of all current services provided at the facility
• A copy of the facility's one year of quarterly reporting of quality outcomes data for the following K / Dialysis Outcome Quality Initiative Indicators (K / DOQI):
  • Urea Reduction Ration (URR) = 65%
  • Urea Kinetic Modeling (Kt / V) = 1.2 Kt / V delivered vs. prescribed dose
  • Hemoglobin of 11-12 grams
  • Hematocrit > 33% for premenopausal females and pre pubertal patients and 37% for adult males and postmenopausal females
  • Albumin of 3.5 to 5.2
  • Note: 80% of all patients must meet the K / DOQI measures

Please include the following documents with your application:
 

• Medicare verification is needed (if applicable).
   

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
     

• Non accredited Pharmacies must submit exemption letter from Medicare.
   

• One of the following accreditation certificates is needed if no exemption letter from Medicare:
   

  • The Joint Commission (TJC)

  • The Community Accreditation Program, Inc. (CHAP)

  • Accreditation Commission for Health Care (ACHC)

  • The Compliance Team Inc's "Exemplary Provider Award Program"

  • Commission on Accreditation of Rehabilitation Facilities (CARF)

  • Healthcare Quality Association on Accreditation (HQAA)

  • National Association of Boards of Pharmacy (NABP)

  • The National Board of Accreditation for Orthotic Suppliers (NBAOS)

  • American Board of Certification in Orthotics and Prosthetics (ABC)

  • Board of Certification/Accreditation International (BOC)

  • A general liability malpractice insurance face sheet for each site (or letter attesting to all covered sites). It must include current coverage dates, provider name, address and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

• Completed application
• Facility Based Crisis Centers must be accredited by one of the following accreditation bodies for the appropriate services:
  • The Joint Commission (TJC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
• A copy of a NC Department of facility services license for (Facility Based Crisis Service for Individuals of all Disability Groups, License .5000)
• A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).

Blue Medicare HMO and Blue Medicare PPO networks only.

Please include the following documents with your application:

• A copy of a NC license or Certificate of Need (if applicable per state or federal regulatory requirements)

• One of the following accreditation certificates is required:

  • American College of Radiology (ACR)

  • Inter-societal Accreditation Commission (IAC)

  • The Joint Commission (TJC)

• Medicare certification

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage ($1 million per occurrence / $3 million aggregate) or letter attesting to all covered sites.

Includes all Home Durable Medical Equipment which includes equipment only and cardiac event monitoring only.

Please include the following documents with your application:

• A copy of the North Carolina Division of Health Service Regulation or North Carolina Board of Pharmacy Permit-Devise Dispensing Permit, Board of Pharmacy Permit-Devise and Medical Equipment

• One of the following documents is needed:
   

  • The Joint Commission (TJC)

  • The Community Accreditation Program, Inc. (CHAP)

  • Accreditation Commission for Health Care (ACHC)

  • The Compliance Team Inc.'s "Exemplary Provider Award Program"

  • Commission on Accreditation of Rehabilitation Facilities (CARF)

  • Healthcare Quality Association on Accreditation (HQAA)

  • National Association of Boards of Pharmacy (NABP)

  • The National Board of Accreditation for Orthotic Suppliers (NBAOS)

  • American Board of Certification in Orthotics and Prosthetics (ABC)

  • Board of Certification / Accreditation International (BOC)

• Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable.

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks Medicare certification is required.

• A general liability malpractice insurance face sheet for each site (or letter attesting to all covered sites). It must include current coverage dates, provider name, address and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

Please include the following documents with your application:

• Home Health Agencies must be accredited. One of the following accreditation certificates or letter attesting to all covered sites is required for each site:

  • The Joint Commission (TJC)

  • The Community Accreditation Program, Inc. (CHAP)

  • Accreditation Commission for Health Care (ACHC)

• All of the following services must be provided in order to meet contracting requirements:

  • Skilled Nursing Visits

  • Speech Therapy

  • Physical Therapy

  • Home Health Aide

  • Occupational Therapy

  • Medical Social Services

• A copy of the Division of Health Service Regulation license is required for each site

• Medicare verification is needed (if applicable)

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate. General liability insurance face sheet must indicate practice / provider address.

Please include the following documents with your application:

• All of the following services must be provided in order to meet contracting requirements:

  • Pharmacy

  • Nursing

  • Supplies

• A copy of the Division of Health Service Regulation License and Board of Pharmacy Permit-Infusion Services is required for each site.

• Home Infusion Agencies must be accredited.

• One of the following accreditation certificates is needed for each site (or letter attesting to all covered sites):

  • The Joint Commission (TJC)

  • The Community Accreditation Program, Inc. (CHAP)

  • Accreditation Commission for Health Care (ACHC)

• Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable.

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

Please include the following documents with your application:  

• Hospice must be accredited. One of the following accreditation certificates (or letter attesting to all covered sites) is required for each site:
  • The Joint Commission (TJC)
  • Accreditation Commission for Health Care (ACHC)
  • The Community Accreditation Program, Inc. (CHAP)
• A copy of the Division of Health Service Regulation license is required for each site.
• Medicare verification is needed (if applicable).
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

Please include the following documents with your application:

• Hospitals must be accredited. One of the following accreditation certificates is required:
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • The Joint Commission (TJC)
  • National Integrated Accreditation for Healthcare Organizations (DNV-GL NIAHO)
  • Center for Improvement in Healthcare Quality (CIHQ)

• A copy of the Division of Health Service Regulation license is required for each site (or letter attesting to all covered sites).

• Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable.

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• A general liability malpractice insurance face sheet for each site (or letter attesting to all covered sites). It must include current coverage dates, provider name, address and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

For cardiac event monitoring services within Blue Medicare HMO and Blue Medicare PPO networks only

Please include the following documents with your application:  

• A copy of the CLIA Full (Level 3) certification or registration (Clinical Laboratory Improvement Amendments) if applicable

• Accreditation by College of American Pathologists (CAP) or Commission on Office Laboratory Accreditation (COLA), American College of Radiology (ACR), or The Joint Commission (TJC)

• Medicare certification is required:

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
     

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage ($1 million per occurrence / $3 million aggregate) or letter attesting to all covered sites.

• Completed Application
• General Psychiatric IOP
  • a copy of a NC Department of facility services license: (Day Activity for Individuals of All Disability Groups, License .5400)
  • Must be accredited by one of the following accreditation bodies for the appropriate services:
    • The Joint Commission (TJC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • Medicare verification is needed (if applicable). 
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement. 
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
  • A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).

• Substance Use Disorder IOP
  • a copy of a NC Department of facility services license: (Substance Abuse Intensive Outpatient Program License .4400)
  • Must be accredited by one of the following accreditation bodies for the appropriate services:
    • The Joint Commission (TJC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
      
  • Medicare verification is needed (if applicable).
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
  • A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).

• Complete Application
• Medically Monitored Inpatient Withdrawal Management must be accredited by one of the following accreditation bodies for the appropriate services:
  • The Joint Commission (TJC)
  • Commission on Accreditation of Rehabilitation Facilities (CARF)

• A copy of a NC Department of facility services license for (Non-hospital Medical Detoxification-Individuals who are Substance Abusers, License .3100)
• A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).

Please include the following documents with your application:

• One of the following accreditation certificates is needed (if applicable):

  • The Joint Commission (TJC)

  • Commission on Accreditation of Rehabilitation Facilities (CARF)

  • Accreditation Association for Ambulatory Health Care (AAAHC)

  • Council on Accreditation for children and family services (COA)

  • Community Health Accreditation Program (CHAP)

  • Continuing Care Accreditation Commission (CCAC)

• A copy of a North Carolina Business license

• Medicare verification:

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• General liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate (or letter attesting to all covered sites).

• In the application, if you've answered yes to any under section 1.G, an explanation is needed. The following information is required if question number C is answered yes:

  • Number of cases less than $200,000

  • If greater than $200,000 actual or anticipated, include the occurrence date, settlement date, and nature of case.

Please include the following documents with your application:

• Division of Health Services Regulation License to provider Opioid Treatment

• DEA

• SAMSHSA Certification ("provisional" SAMSHSA Certification will not be excepted)

• Letter of Certification from SAMSHSA

• Medicare Provider Number

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• National Accreditation (CARF, Joint Commission, Council on Accreditation, and National Commission on Correctional Health Care)

• General and Professional Liability. It must include current coverage dates, facility name, facility address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate. 

• Contracting requirements are listed below:

1. Methadone Treatment
2. Individual psychotherapy
3. Buprenorphine / Naloxone Treatment
4. Intensive Outpatient Treatment
5. Family Psychotherapy
6. Group Psychotherapy
7. Psychiatric Evaluation

This includes all Orthotics and Prosthetics which will include Breast Prosthetics only.

Please include the following documents with your application:

• One of the following accreditation certificates is needed:

  • The American Board of Certification (ABC)

  • The Board of Certification / Accreditation International (BOC)

  • Commission on Accreditation of Rehabilitation Facilities (CARF)

  • Community Health Accreditation Program (CHAP)

  • HealthCare Quality Association on Accreditation (HQAA)

  • National Association of Boards of Pharmacy (NABP)

  • The Joint Commission (TJC)

  • The Compliance Team, Inc.

  • The National Board of Accreditation for Orthotic Suppliers (NBAOS)

  • Accreditation Commission for Health Care, Inc. (ACHC)

• Medicare verification is needed (if applicable).

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

• Substance Abuse Comprehensive Outpatient Treatment Program (SACOT)
  • A copy of a NC Department of facility services license: (Substance Abuse Comprehensive Outpatient Treatment (SACOT), License .4500)
  • Must be accredited by one of the following accreditation bodies for the appropriate services:
    • The Joint Commission (TJC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).
  • Medicare verification is needed (if applicable).
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
• Partial Hospitalization for Individuals who are Acutely Mentally Ill
  • A copy of a NC Department of facility services license: (Partial Hospitalization for Individuals who are Acutely Mentally Ill, License .1100)
  • Must be accredited by one of the following accreditation bodies for the appropriate services:
    • The Joint Commission (TJC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).
  • Medicare verification is needed (if applicable).
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

Please include the following documents with your application:

• Private Duty Nursing must be accredited. One of the following accreditation certificates (or a letter attesting to all covered sites) is required for each site:
  
  • The Joint Commission (TJC)
  • The Community Accreditation Program, Inc. (CHAP)
  • Accreditation Commission for Health Care (ACHC)
• A copy of the Division of Health Service Regulation license is required for each site. 
• Medicare verification is needed (if applicable).
  
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

Please include the following documents with your application:

• CLIA certificate Full (Level 3)
• Accreditation by College of American Pathologists (CAP) or Commission on Office Laboratory Accreditation (COLA) or The Joint Commission (TJC)
• If not accredited by an accrediting agency (CAP, COLA, or TJC) needs CMS site survey
• Medicare certification
  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.
  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.
• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

Please include the following documents with your application:  

• Residential Treatment / Rehabilitation for Individuals with Substance Abuse Disorders
  • A copy of a NC Department of facility services license (Residential Treatment / Rehabilitation for Individuals with Substance Abuse Disorders, License .3400)
  • An accreditation certificate or current NC State Site Survey / Statements of Deficiencies (SOD) is required.
  • We accept accreditation from the following:
    • The Joint Commission (TJC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).
• Psychiatric Residential Treatment for Children and Adolescents
  • A copy of a NC Department of facility services license (Psychiatric Residential Treatment Facility for children and adolescents, License .1900)
  • An accreditation certificate or current NC State Site Survey / Statements of Deficiencies (SOD) is required.
  • We accept accreditation from the following:
    • The Joint Commission (TJC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).
• Psychiatric Residential Treatment for Adults
  • A copy of a NC Department of facility services license (Supervised Living for Adults with Mental Illness, License .5600A)
  • An accreditation certificate or current NC State Site Survey / Statements of Deficiencies (SOD) is required.
  • We accept accreditation from the following:
    • The Joint Commission (TJC)
    • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • A general liability insurance face sheet is required and must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).

Please include the following documents with your application:

• If not accredited, please provide a copy of the most recent CMS Review.

• If you are qualified and enrolled with the National Supplier Clearinghouse as a Medicare certified DMEPOS supplier one of the following accreditation certificates is needed:

  • The American Board of Certification (ABC)

  • The Board of Certification / Accreditation International (BOC)

  • Commission on Accreditation of Rehabilitation Facilities (CARF)

  • Community Health Accreditation Program (CHAP)

  • HealthCare Quality Association on Accreditation (HQAA)

  • National Association of Boards of Pharmacy (NABP)

  • The Joint Commission (TJC)

  • The Compliance Team, Inc.

  • The National Board of Accreditation for Orthotic Suppliers (NBAOS)

  • Accreditation Commission for Health Care, Inc. (ACHC)

• Copy of the Division of Health Service Regulation license

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, and limits of coverage. Minimum coverage for all networks is $1 million per occurrence / $3 million aggregate.

• Medicare verification is required for each site (or letter attesting to all covered sites).

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• On the application, if you've answered yes to any questions under section 1.G, an explanation is needed. The following information is required if question number C is answered yes:

  • Number of cases less than $200,000

  • If greater than $200,000 actual or anticipated, include the occurrence date, settlement date, and nature of case.

Please include the following documents with your application:

• Medicare certification is required (if applicable).

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• One of the following accreditation certificates is needed (if applicable):

  • The Joint Commission (TJC)

  • The Community Accreditation Program, Inc. (CHAP)

  • Accreditation Commission for Health Care (ACHC)

  • International Standards Organization (ISO)

  • The Compliance Team Inc.'s "Exemplary Provider Award Program"

  • American Academy of Sleep Medicine

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).

Please include the following documents with your application:

• Board of Pharmacy Permit-Devise and Medical Equipment Permit is required

• Medicare certification is required.

  • Note: Medicare verification is needed for each site (or letter attesting to all covered sites) if applicable. A current one-page copy of a Medicare Remittance Advice Summary (RA) from the facility, no older than 3–6 months with PHI redacted, will meet this requirement.

  • Note: If applying for the Blue Medicare HMO and Blue Medicare PPO networks, Medicare certification is required.

• A general liability malpractice insurance face sheet. It must include current coverage dates, provider name, address, or letter attesting to all covered sites, and limits of coverage ($1 million per occurrence / $3 million aggregate).

• A copy of the CLIA certification or registration (Clinical Laboratory Improvement Amendments) if applicable.

• Accreditation by URAC

• In lieu of the Accreditation by URAC, we can accept pharmacies that have received federal designation as a Hemophilia Treatment Center