Ambetter is one of the largest commercial medical insurance companies in the country. In New York State, Ambetter doesn’t directly provide its services under its name. Rather, the company offers its solutions in NY via Fidelis Care. Fidelis Care itself is a Centene Corporation subsidiary and is a New York-licensed health plan with more than 2.4 million members statewide.
For healthcare providers in NY, Ambetter credentialing isn’t via a separate entity. The process actually runs through Fidelis Care’s own credentialing department, and it sits alongside New York’s own provider protection rules.
We have created this guide to simplify the Ambetter provider credentialing process for you. By the end of this guide, you will know everything that you need to complete the process with ease. So, let’s start.
Ambetter NY Provider Enrollment & Credentialing Requirements
Let’s now begin with the important part: Ambetter New York credentialing requirements and the process.
We have already mentioned that Ambetter operates in New York State as a Fidelis Care product. So, naturally, every application in the state is submitted using Fidelis Care’s provider application page or the CAQH ProView application form. After you submit the application, it is processed and presented to the review committee.
In most cases, this committee then makes a decision within 60 calendar days. However, this is contingent on the fact that you provided all the required documents. If you fail to provide the required documents, the application won’t be presented to the committee.
For New York State Ambetter credentialing, you need the following documents:
- Provider data form
- Authorized and re-attested CAQH application, including office hours, panel status, age limits, and malpractice case info
- Copy of current appointment/reappointment letter from all hospital affiliations
- Copy of board certificate (or eligibility letter), if applicable
- If not board certified, copy of residency completion certificate(s)
- Signed Medicare attestation form (only if you have current hospital affiliations)
- W9 form
- For NPs/PAs/CNMs/CRNAs: name and phone number of supervising/consulting physician
- Covering practitioner(s) info
- Collaborating agreement (NP/PA/CNM/CRNA)
- Medicaid number (MMIS)
Some other documents that must be a part of the Ambetter credentialing packet include:
- Copy of current professional liability insurance certificate specifying limits per your agreement
- Copy of current DEA certificate, if applicable
Another important point to note here is that after getting credentialed with Ambetter in New York, every healthcare provider must get re-credentialed every three years. If they fail to do so, they will be terminated, and no claims will be reimbursed.
New York State Ambetter Credentialing Application Guidelines
Once you have arranged all the documents, the New York State Ambetter enrollment and credentialing process becomes quite straightforward. Here are the key steps that you need to follow:
Step 1: Authorize Fidelis Care Inside CAQH ProView
Fidelis Care pulls license, malpractice, education, and background information directly from CAQH ProView. So, you should open the ‘Authorize’ tab in ProView and give Fidelis access as a participating organization.
This is the first step, and the next steps cannot be completed without it. Also, an important point that you must note here is that if your CAQH profile is not re-attested within CAQH’s deadline (typically every 120 days), the credentialing process will stall.
Step 2: Submit the Provider Application
Once you provide access, the next step is to submit Fidelis Care’s provider application or the CAQH ProView application form, along with a signed contract and the documentation we mentioned in the previous section.
An incomplete Ambetter New York credentialing application or an application with inaccurate information won’t reach the committee for review. So, make sure to pay extra attention to this step.
Step 3: Credentials Committee Review
Fidelis Care’s Credentials Committee reviews the file against its verification standards and issues a written decision.
This is usually done within sixty calendar days after you submit the application.
Step 4: Provisional Credentialing, Where Eligible
A provider who is newly licensed in New York, or who has relocated to New York and has not previously practiced in the state, can qualify for provisional credentialing if that provider joins a group practice that is already enrolled with Fidelis Care and submits a completed application.
Provisional status becomes available if Fidelis Care has not responded to the completed application within ninety days, at which point the provider is treated as a participating provider as of the day following that ninetieth day. But please keep in mind that this only applies if you join an already enrolled practice. It does not extend to a solo practitioner opening a new, unaffiliated practice.
Key Challenges in Getting Credentialed with Ambetter in NY
Even though the process that we explained above sounds simple, there are still some challenges with the NY State Ambetter provider enrollment process. Take a look at the key issues that we think are most prominent:
- 90-Day Rule Only Covers Certain Providers: The provisional credentialing rule only helps providers who are new to New York or just got licensed, and only if they join a group already working with the plan. Solo practices or providers switching groups within the state do not qualify. Late payment penalties also do not apply during this waiting period.
- Provider Networks are Checked County by County: A big problem is that most insurance companies first report their provider networks to the state. The state then checks if each county has enough providers. Now, since Ambetter’s coverage area is usually set by county, a healthcare provider who recently got his credentialing approval may not show as credentialed right away. It takes some time to get updated. Until then, the provider might not get reimbursed.
- Behavioral Health Providers Get Extra Checks: Starting July 1, 2025, insurers must contact behavioral health providers at least once a year to make sure their listing is correct. If someone reports a mistake, the insurer has fifteen days to fix it. Providers should respond quickly when asked to confirm their information.
- Provider Directories are Being Watched Closely: A while ago, the state started an investigation and, quite surprisingly, found that many behavioral health listings were wrong. Some healthcare providers were not taking any new patients and worked someplace else. This is a kind of fraud. This shows why providers need to keep their information updated with Fidelis Care at all times.
Conclusion
That’s it! We’ve reached the end of our guide to credentialing with Ambetter New York. We understand that all the technical jargon can be a bit difficult to understand. We tried our best to simplify it for you. Ambetter or Fidelis Care is one of the biggest health insurance payers in NY. So, getting credentialed with them is essential to expand the patient base and increase revenue.
However, even with all the guidelines, the credentialing process can be very frustratingly long and complex. That’s why it is better to get help from professionals. Our team at NeuraBill offers expert insurance credentialing services that are sure to fast-track your Ambetter credentialing process.
