• Credentialing

  • Welcome to the credentialing page for participating providers of Affinity Health Plan. Here, you will find information and documents to help you learn about and complete the credentialing process. Participating providers can also use these resources for re-credentialing. If you have questions about credentialing, you may also contact our provider relations, contracting and credentialing department.

    Affinity has simplified the provider credentialing process by adopting the Universal Credentialing DataSource developed by the not-for-profit Committee for Affordable Quality Healthcare (CAQH). Providers registered with CAQH need to complete the online credentialing application just once, and then select the organizations who may access it. Other benefits of CAQH credentialing:

    • Registration is no-cost and hassle-free (no paperwork)
    • Information security (assured through password protection)
    • Regular information updates (status change requests are limited to three times yearly)

    Credentialing/directory listing for ID/AIDS/HIV providers

    AIDS/HIV providers may be listed in the Affinity provider directories as AIDS/HIV Specialists or as “HIV Experienced Providers” if they meet certain criteria:

    • An MD or Nurse Practitioner providing ongoing direct clinical or ambulatory care of at least 20 HIV infected persons who are being treated with antiviral therapy in the proceeding 12 months.
    • A provider who has met the criteria of one of the following accrediting bodies:
      • The HIV Medicine Association (HIVMA) definition of an HIV experienced provider.
      • HIV Specialist status accorded by the American Academy of HIV Medicine (AAHIVM).
      • Advanced AIDS Credited Registered Nurse Credential given by the HIV/AIDS Nursing Certification Board (HANCB).

    Documentation to support “HIV Experienced Provider” status can be submitted to your Affinity Provider Relations representative.

    Certain providers joining a participating group practice may be provisionally credentialed. If a completed credentialing application is received for a health care professional who satisfies all the conditions of Columns A, B, C below, and we have not approved or declined it within ninety (90) days, the health care professional will be deemed “provisionally credentialed.”¹

    Column A Column B Column C
    1. Is newly-licensed; or
    2. Recently relocated to New York from another state and has not previously practiced in New York
    Joined a group practice of health professionals each of whom participates as an in-network provider in the Affinity His or her group practice has notified Affinity in writing that, if the application ultimately is denied, the health care professional or the group practice:
    1. will refund any payments made for services provided by the provisionally credentialed health care professional that exceed any out-of-network benefits payable; and
    2. shall not pursue reimbursement from the Member, except to collect the co-payment that otherwise would have been payable had the Member received services from an in-network provider

    A provisionally credentialed health care professional may participate with Affinity as an in network provider but may not serve as a Primary Care Provider (PCP) until such time as he or she is fully credentialed.²

    Interest and penalties described in New York prompt pay law do not have to be paid on the denial of claims submitted by a health care professional during the period he or she was provisionally credentialed. Claims submitted by a provisionally credentialed health care professional will not be denied, after appeal, solely on the basis that the claim was not submitted timely.³

    Ownership, Debarment and Criminal Convictions

    Before Affinity enters into or renews an agreement with your practice or corporate entity, you must disclose any debarment or suspension status and any criminal convictions related to federal health care programs of yourself and your managing employees and anyone with an ownership or controlling interest in your practice or corporate entity.

    In addition, if the ownership or controlling interest of your practice or corporate entity changes, you have an obligation to notify us immediately. This also includes ownership and controlling interest by a spouse, parent, child or sibling. Please contact us by using the contact information in the reporting section below. If you have ownership of a related medical entity where there are significant financial transactions, you may be required to provide information on your business dealings upon request. If you fail to provide this information, we are prohibited from doing business with you. Please refer to the Code of Federal Regulations (CFR) 42 CFR 455.100-106 for more information and definitions of relevant terms.

    All requests for disclosure of ownership, controlling interest, business transactions, or related information made by Affinity or a governmental agency must be fulfilled within 35 days of the date of a request. It should be noted that at minimum, Affinity providers, vendors, and business partners must review the Social Security Administration's Death Master File, the National Plan and Provider Enumeration System (NPPES), the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE), the General Service Administration (GSA) Excluded Parties Lists System (EPLS), and the New York State Office of Medicaid Inspector General (OMIG) Medicaid Terminations and Exclusions list prior to hiring or contracting of any new employee, temporary employee, volunteer, consultant, governing body member, or First Tier, Downstream, and Related Entity (FDR) to ensure that none of these persons or entities are excluded or become excluded from participation in federal or state programs. The LEIE and EPLS screenings must also occur at least monthly thereafter; the OMIG Medicaid Terminations and Exclusions list must be checked periodically after being hired or contracted.

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    ¹ NY Pub Health § 4406-d.1(b).
    ² NY Pub Health § 4406-d.1(b).
    ³ NY Pub Health § 4406-d.1(b).