Provider Credentialing Applications and Policies

CAQH Provider Application - Physician

If you have a CAQH profile and you are a(n):

• Allopathic Physician (MD).
• Osteopathic Physician (DO).
• Podiatrist (DPM).

CAQH Provider Application - NPMP & Allied

If you have a CAQH profile and you are a:

• Physician Assistant (PA).
• Nurse Practitioner (NP).
• Licensed Midwife (LM).
• Certified Nurse Midwife (CNM).
• Certified Registered Nurse Anesthetist (CRNA).

Complete Physician Provider Credentialing Application

If you are a(n):

• Allopathic Physician (MD).
• Osteopathic Physician (DO).
• Podiatrist (DPM).

Complete Non-Physician Medical Practitioner Credentialing Application

If you are a:

• Physician Assistant (PA).
• Nurse Practitioner (NP).
• Licensed Midwife (LM).
• Certified Nurse Midwife (CNM).
• Certified Registered Nurse Anesthetist (CRNA).

Complete Allied Provider Credentialing Application

If you are a(n):

• Physical Therapist.
• Occupational Therapist.
• Speech Therapist.
• Audiologist.
• Hearing Aid Dispenser.
• Optometrist.
• Acupuncturist.
• Chiropractor.
• Psychologist*
• Licensed Marriage & Family Therapist*
• Licensed Clinical Social Worker*
• Licensed Professional Clinical Counselor*
• Board Certified Behavior Analyst*
• Qualified Autism Services Provider*

*These provider types will be credentialed and made active no sooner than July 1, 2025. Applications should still be submitted prior to July 1, 2025.

Complete Organizational Provider Application

This application should be completed by the following:

• Ambulatory Surgical Center (freestanding only).
• Home Health Agency.
• Hospital (all types).
• Skilled Nursing Facility/Long Term Care.
• Hospice.
• Sleep Center/Sleep Lab (freestanding only).
• CBAS (ADHC).
• Freestanding Birth Centers (licensed only).
• Residential Treatment Facility*
• Residential Detox Facility*
• Eating Disorder Facility*
• Mental Health Rehabilitation Center*
• Alcohol and Drug Outpatient Facility*

*These provider types will be credentialed and made active no sooner than July 1, 2025. Applications should still be submitted prior to July 1, 2025.

Complete Durable Medical Equipment Provider Application

If you are interested in providing the CHW Benefit to Alliance members in Merced, Monterey and/or Santa Cruz counties, you will need to apply to be credentialed.

To be credentialed and start work as an Alliance provider, you will need to complete the following steps.

Be screened and enrolled as a Department of Health Care Services (DHCS) Medi-Cal provider.

All CHW Care Based Organizations are required to enroll with DHCS. Providers must enroll in Medi-Cal if a state-level enrollment pathway exists. To do so, use the standardized application form for the DHCS Medi-Cal program. You will need to create a User Profile on the website to do so.

If a CHW Care Based Organization is a non-traditional provider type for whom there is no established credentialing pathway, the Alliance will verify the provider’s credentials through Alliance credentialing in addition to requiring any or all the following documents:

• Applicable business or professional license.
• IRS Form 990.
• Nonprofit status.
• Other documentation demonstrating official established business and/or individual entity.

Submit an Alliance credentialing application and all the required supplemental forms to become an Alliance provider.

Have a contract with the Alliance that includes these services.

New Provider Training

Once you have completed these steps, you will also need to complete the Alliance’s New Provider Training.

Ready to start applying? Please follow the directions in the Community Health Worker Organization Provider Credentialing Application.

If you have any questions, please contact [email protected].

Become a Doula at the Alliance Checklist

• Department of Health Care Services Medi-Cal Enrollment - Provider Application and Validation Enrollment (PAVE)
  • NPI (National Provider Identifier) (How to obtain an NPI)
  • HIPAA Training Attestation
  • CPR Certification
  • Business License
  • Insurance
• Contract & Credential with the Alliance
  • Credentialing Application
  • Provider Information Request
  • W9
  • Sign Contract
• Training
  • Member Eligibility
  • Claims Submission (Coding, Modifiers)
  • CHC Set up

Complete Doula Provider Credentialing Application